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HomeMy WebLinkAbout1814A �� I WORKERS'COMPENSATION DECLARATION ��� ���81 qpp�{CATlOIV FOR EL�CTRICAL PERMIT% �7 ' � � I hereby affirm tho� I have a certificate nf mnseM to self �E'�G � � // insure,or a certifimte of Worke�s'Compensa�io�I�suronce, [QUNTY OF LOS ANGELES BUILDING AND SAFET16c____._� or o certifled copy ihereof�Sec.3800,Lab.C.J PoliCy No�ompony�N�✓�(�I,�I�}"C . FOR APPLICANi TO Hll IN J06 � �'L / �,--/, Certified copy is hereby furnished. /NQ New Residential Bldgs.& ools EACH NO. FEE '��RE55 �.YJ YXI Cer�ified copy is filed with the caunry 6uilding inspec- y,Sq.R. — �OCAIIT 1 8 2-Fomil $ — E - "c.'t �hpq��ep tment. Multi-family Sq.Ft. Ce055 ST. pate'r/J°� � Applimn Residential Swimming Pools OwNER OR FIRM NAME N CERTIFICATE OF EXEMPTION FROM WORKERS' Outlefs:Rec._Light_Sw.� ��� �(� �X „��a 9' COMPENSATION INSURANCE ADDRESS (Tl�ia s�ciion nwd nof bo complatod if 1ho work Invotv�d by F���� CIT Tel.N Tha parmlt ta for ona h�ndrod dolbrs(�100)or lo�a.) Totol No. Addit�onal I✓Q. ��/�� 7 I certi that in the rformonce of�he work for which ihis PtANCHECK fV . Pe AVMIC4NT permit is iuued,t sholl not emp�oy nny person in any manner so as to 6ecome su6ject to ihe Wwkers'Compensetion Laws. Lighting Fixtu�es First 20 ADDRE55 Total Na. Addilionol CITY Tel.No. Date applica�t Fized Appliances Not Over 1 HG pERt�M1�T � y OTICE TO APPl.ICANT: If, aRer making this Certificate of APMiCANT ^� �771L/G '( Remplion, you should 6ecome subject to the Workers' Range_Heater_D.W. _ Compensafion provis�ons of the Labor Code,yoo musf forrh- Oven _Oryer _W.M.�. ADDRESS ��,�� ��� with comply with such provisions or this permit shaii be Top _FAU —W.H._..._ deemed revoked. CITY �/(�� 9r7�Tel.No. ���j � IICENSED CONTRACTORS DECIARATION Hood ____Fan _Other_ IICENSE OR - p-� � I hereby affirm that!am licensed urder provizions of Chapter 9 Disp. _Room Air Cond. — REG.NUMeER 6.J Ciass. ��/ (commencing with Section 70001 of Dirisiort 3 of the Business DISTRICT N0. PROCESSED BY } and Professions Code, nd my license is in full force ond effect. Power Apparatus 8 Large Appliances �-: � C IU Size 8 Type HP,KW,KVA,or KYAR �,O �`d n � license Nvmbe�_(L���Lic.Clas s�`, Up to 1 incl. fINAI J L� � �-��Z��C�� 7/ Over 1 to 1Q IncL �ATE �'3O_y� VALIDATION ,.�- s Conhacto Date l O�er 10 io 50 incl. W FINAL � � I am exemp�under Sec. Over SO�0 100 Irrc. BY p, � Over 100 � " 8.8P.C.ior tMis reaaon Z i Date: Services,Sw6d.,MCC 8 Panelboards � :__ � G ;,u.P• 0-20�Amp.Under 600 V � Signoture 207-1000 Amp.Under 60D V �*° • ` ° °� ❑ Over 1000 Amp.o�Over 600 V Exemplion for Reg.NwinL Eled. � ° I G SINGLE FAMILV Temp.Power Pole 6 Appurtenances • :, i '; � HOME OWNER-BUIIDER DECLARATION Sign with One 8ra�+ch Circ�it � � iereby affirm thai I am exempt from ihe Conirattor's License qddirional Sign Brench Circuits C��r=-'�. % � iaw for the following reoson(Secfion 7031.5,Bueiness and Profeuions Code): ❑ I,os owner of the o t,will do the work and the Misc.Conduits 8 Conductors pr per y pther See Com lete iee Schedule strodu�e is nol intanded or offered far sale (Section ( P )— � 7044,Business ond Professions Code). CONSTRUCTION LEN�ING AGENCY I hereby affirm that there is a consiruction lending agency for the pe�formance of the work far which�his permii is issued pERMIT FEE (S�b-To�oI) ($ec 3097,Civ.C.). �4 9� PLAN CHECKiNG FEE i lender's Name a PERMIT ISSUING fEE lender's Address I certify thot I have read this application and state thot rhe TOTAL FEE �`1 ��� a6ove informafion is corred.I agree to mmply with all County � ordinances ond State laws regulating Electricol wiring, and f hereby authorize represenlatives of ihis County to enter upon � r bove-memioned property for inspedion r oses. SEE REVERSE FOR EXPIANATORY LANGUAGE /�'x''.��- `�/S/l� � Signoture of Pe�mittee Date �vi'i r d m a�'r .n .� c ._ 'o .~ „ a,.c rs� � � . o " � � � aa.°' � � � c° O�v` . ..2 . b � � �`a o � 7� Cy � `�� 3 � t%� o G 4 t � C t O lj o 0� 4� O S � � p � �'L• C O V� '� 3 y � 4 + ] •Q:L � - J G 7 c' �''� m � .� C,� � � m FL- 0 p N 07 4 Qi�� i � � E C 4.0 w�, O o n o o � a � o c �C o � C 3 � ` 4 ? 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