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
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