HomeMy WebLinkAbout1774A WORKERS'COMPENSATION DEClARA710N 76Ae63 t0i81 qpp��CATION FOR ELECTRICAl. PERMIT ` � w�
I here6y affirm�hat 1 have a cer�ificate of consen�to seR
CE-806C �� ��
insure,or a cerlificote of Workers'Compe�sa�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certifi w y thereof(Sec 3800,Lob.C.)
P❑oHq No`.��ompany �/�/�US/ic-j/'F'L FOR A►►UCANT 70 FILL IN 1OB '
Certified co �s hereb f�rnished. EnCH NO. FEE A�IN2Eu �'
py� Y fN/�� New Residentiol Bldgs.8 PPP Is�-�/ .—f'i,,,, �1
(� 1 8 Z-Fomil S Ft.� f = s LOCAUT � a�0 ��3
iy Certified mpy is filed with ihe coonty 6uifding inspec- Y• 4�
dep rtment, Multi-fomily Sq.FI. CROSSSST.
ResidentioV Swemming PooVs OWNER OR
Dote�� � Applican FIRM NAME �
CERTIFICATE Of EXEMPTION fROM WORKERS' Outlels:Rec_Light_Sw._ " � ��� /�
COMPENSATION INSURANCE A�DRESS - . x, 7 I
First 20
(Th{s a�ction nNd no1 b�complrF.d H th�work[moirad by 7otnl No. Addilional CIT n/a,qf��, Tel.No. � � j
fhe prrmll Fs for ana hundnd dolkro(t100)or less.)
PlAN CHECK �
1«rlify�ha�Yn Ihe performance of�fie work for whicb�hls APPIICANF �
permir is iss�ed,I sholl no1 employ ony person in any manner
so os m bemme aubject to�he Wahen'Compenmtion laws. LigMing Firtures First 20 AODRF55
Addilional
Total No. CITY Tel.No.
Date 6PP��ro^j Fixed Appliances Not Over 1 HP pERMIF .+�p
� CE TO APPIICANT: If, nfter mpking this Cestificale of qpp���T �
�ption, you should become su6jed ro tha Workers' Ronge_Healer_O.W._
�Compensotion provisions of Ihe Labor Code,you musl forlh- Oven _Dryer —W.M.— � ADDRE55 , v � �/��
with comply with such provisions or this permi� sholl be Top _FAU _W.H.— J, ,l /��
deemed re�oked. 1-iood _Fan _Other_ CITY /K J Tel.N .
LICENSED CONTRAC70R5 OECLARATION uCENSE OR /�]..�� ,,e� �1 �
Disp. ..,Room Air Cond. — REG.NUMBEH !/C/ � ��""��V
i he(e6y oHfn„rhot t am licensed under provisions of Chapter 9 Q
(commenNng with Section 700p)of Division 3 of the Business power Apporatvs 8 Lorge Applionces DISTRIC�NO. PROCESSED 8Y O �
ond Profassians Code,and my licen5e is in full force and effe<t. <
��p,,j)�� Si:e 8 Type HP,KW,KVA,or KVAR � �Q`O n U
License N�mber_���s��_lic.Gnss �� � UP fo I IncL FINAL '` �
L O �
� � OATE I VAUDATION V �
�—�7 Over 1�0 10 Ind. y �`� I
Gontroctore�`���� Date Over 10 to SQ ind. FINAL � �
� 1 am exempt ur+der Sec. Over 5�ta I00 Irrc. BY N �
B.BP.C.for this reoson Over IQO � Z �
Services,Swbd.,MCC 8 Panelboa�ds � �
�O�e1 0-200 Amp.Under 600 Y ZE
Signature ZDI-)000 Amp.Under 600 V �
aOver 1000 Amp.or Over 600 V z � / !,-;ti
Ezemption for Reg.Maint.Eled- � �
SWGLE FAMIIY Temp.Power Pole&Appurfenances � � � � ��
HOME OWNER-BUILDER DECLARAFION 5� ��,,�ith One eranch Circuit
i;� �by affirm rho�1 am exampt from�ha Conhaclor's License 9 � � 4'1 f-.","��
Law for the following reasan (Settion 7031.5, 8usiness ond Addioonal Sign Branch Circoits
Professions Code): • e e j!„=,_?=
❑ I,as owner of ihe properly,will do�he work and the Misc.Conduits 8 Conducfors
G9,22—: r.
sirudure is not in�ended or offered far sale (Seciion Other(Sea Complete Fee Schedule)_ �
7044,Business and Profeszions Code).
CONSTRUCTION LENDlNG AGENCV
I hereby affirm�hat there is a construdion lending agency for �
the performance of ihe work for which this permit is issued VERMIT FEE (Sub-Total) ,�Q
(Sec 3097,Clv.C.j.
PLAN CHECKING fEE
lender's Name �
PERMIT ISSUING PEE
Lender's Address /_ p
I certify iho�1 have read ihis application and state rho��he TOTAd FEE �!� O
above intormatio�is corred.i agree to comply with all Counly
ordinonces and S�ate lows regolating Eledrical wiring,ond •
hereby authorixe representatives of this Couniy to enter upon
the e-mentioned proper�y for�nspad�on p�rpo es. SEE REVERSE FOR EXPLANATORY LAN6UAGE
��� �'�s� �
$ignoture of Perminee Da�e
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