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HomeMy WebLinkAbout1813A � I WORKERS'COMPENSATION DECLARATIQN �aAe6J t0i81 qpp��CATlOiV FOR ELECTRICAL PERMIT /� � I hereby affirm that I ha�e a certificale of consent to self CE�BObCi � insure,or a cer�ifimte of Workeri Compenwt�on Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFET � or a certi�f"����,opy thereof(Sec.3800,La6.C.) P❑olfty No:"-'�Compony�� ✓ • FOR APPLIGNT TO Flll IN JOB Ce�tified co is here6 furnished. /N EnCH NO. FEE ADORE55 PY Y New Residential Bldgs.8�09���j (� 1 8 2-Fomif F�. // 5 = S LOCAUTY � � .� �" ��y Cerffie��filed with the coonty building inspeo- Y'�� NEAREST �T dep rrmenr. Multl-family Sq.Pr. 7 � �� ��� Res�deetial$wimming Pools OWNER OR �ote Applicai fiRM NAME N �h� CERTIFICASE OF EXEMPTION FROM WORKERS' Ourlels:Rec._Light_Sw._ DORE55 X COMPENSATION INSURANCE ' hls wefion neaa net 6�eem IN�d if 11�e work imolrvd 6 first 40 (T P Y iotal No. Additional CIT N � �,.Tel.Noq6� fha p�rmlt b ior aw hundrod dollan(�106)ar lass.j PIAN CHECK 1 certify thot in the perfwmonce of the wwk for whith this APPLICANT permit is issued,1 sha!!not employ any person in any manner so as to become su6ject ro the Warkers'Compensation laws. L�9hting FixWres First 20 A�DRE55 Total Na. Additional CITY Tel.No. pate opplicnnt Fixed Appliances Not Over 1 HP pEkl�nii w v-�A� y CE TO APPIICANT: If, ofter moking this Certificvte of ApaUG4NT � C�V�`-�a.1 b. �pNaa, you should become subjed to the Workers Ra�ge_Heater_D.W._ Campensation provisions of the Labo�Code,you mus�forth- Oven _Dryer ._._W.M.� AD�RE55 ,(,� X � � with comply wifh wch provisions or this permit shall be 7op _fAU —W.H.� demmed revoked. CITY 9/'f(7�Tel.No����Q� Hood _Fan _Other_ LICENSED CONTRAC70RS DEQARATION IICENSE OR �'�7 /�'`,�1 I heraby affirm thal 1 am licensed under provisions of Chapter 9 d��' —Room Air Cond. .— REG.NUN9ER 7�/�� ���"s`�y/4 } (wmmenung with Saction J000�of Division 3 of the Business po„"er Appora�uc 8 Lorge Appliances OfSTRICT Np. PROCESSED HY d' ond Rofessions Code,ond my license is in fult force and eHecr. ,(�,, II��U� �_ Size 8 Type HP,KW,KVA,or KYAR �O �`b..`O/� License Number �r Lic.Class� FINAL � /�/� Up to 1 ind. OATE � O ,�J / Over I to 10 Incl. 3-2u- VpLIDATION f- Contractor c ,�Z'�'�� �a1e l Over 10 to 50 lncl. � aFINAL W � I om exempt under Sec. Over 50 ro 100 Irtc. 6Y N� � B.&P.C.�or this reaeon �g��� Z � Date: Services,Swbd.,MCC 8 Panelboards � � 0-200 Amp,U�der 6Q0 V Signature 201-1000 Amp.Under 600 V `} Y j `r, � ❑ Over 1000 Amp.a Over 600 V � E:amption for Reg.MainL Eled. � � e � SiNGLE FAMI�Y N� •` � Temp.Power Pole 8 Appur�enonces . HOME OWNER-BUIL�ER�ECLARATION I a I � i.� �=� � $i4n with One&an[h�irCuit t� eby affirm tho�t om exempt from the Connodor's License qddirional Sign B�anch Cirwih s r ��? � law for the following rea5o�(SeUion 703L5, Business and � � � - �-� � Professions Code): _ ❑ I,os owner of fhe property,will do Ihe work ond the M�sc.Conduih&Conductors �S�.C c-'i: struciure is not intended or oftered for sale (Section Other(See Compiete Fee Schedule}_ � 7044,Business and Professions Code). CONSiRUQ10N LENDING AGENCY � I here6y offirm tho�there is o consirodion lending agency for Ihe performance of the work for which this permit is issoed PERMIT FEE (Sub-Total) li(� (Sec.3097.Liv.C.). { PIAN GHECKlNG FEE � �ender's Nome PERMI7 ISSUING FEE � lender's Address /� ��p_ I certify thot I have read this applica�ion and stote that the TOTAL FEE Sf�p � a6ove information is mrrec�.1 ogree�o comply wiih all Covnry ordinances ond Sta�e�aws regulaling Elecirical wiring, o�d � here6y a�lhorize rep�esentatives of ihis County to enter upon � ihe �e-menlioned property;o�inspectio 0 oses - ��� ����� SEE REVERSE FOR EXPIANATORY IANGUAGE t. ISignature of Perminee Date �rO vi�„ 0� N �� � '�-O 7�. ` 'P--� � �y O �`T1 . 1 I . _ . . ti � q O „ C L � „0 3"� ° �o ; o.A � oc e a � � c.°'c � a^ �s. Eo-q ' �'a`r"' m.c' o V° nm °T' ° o I � m e� � 'u� -t o .��. a� .t.� ' :° ° ��° a� o,� anc ° y ,i 3m.co� c'° c -� I � Z i. u ? 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