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HomeMy WebLinkAbout1801A i� WORKERS COMPENSATION DECIARATION 76Ae63 IOi81 qpp��CATlON FOR ELECTRICAL PERM,� J � I hereby offirm tha� I hove o cerlifim�e of consen�b self CE-8p6G ` insure,or a cerrificate af Workers'Compensation Insurance, COUNTY OF LOS ANGELES Bl11LDiNG AND SAFC�Y'�--�' o�a�cer�ifi d copy ihereof($ec.3800,Lab.C.) V❑olicy No`��Omppny�NOI/S.I��/�� FOR APPUCANT 70 FILL IN JOB p ,(" I Certified co s hereb fumished. EACH NO. FEE ADDRE55 7 tJ �-7 PY' Y //�. New Residential Bldgs.8Po I l �y� Certified copy is filed with the county building insper �8 2-Family,Sq.F�. '^� � s — s Q �0��� �p� /_ i "���' � depa tmenr. Multi-family$q.FI. CRO55 ST. . �� Residential$wimming PooVs OWNER OR „`O"� ` Dnte Applican FIRMN 1V �/�•' CERTIfICATE OF EXEMPTION FROM WORKERS' Outiets:Rec,_light_.Sw._ � �"�� COMPENSATION INSURANCE F,5 p ADDRESS • , X (TMIa aocibe npd�wf be tumpleled if fhe work tnvolrad by To�al No. Addilional ��T (f il/Q ��j�o�. Tei.No.�j 7�Y�,/ Nw ponnil k{or on�hu�rad daNan(5100)or lets.) vIAN CMECK 1 cer�iiy thai in the performnoce of�he work for which this qpp���Nf permit is issued,1 shall nol employ any person in qny monner , so as to become subjett to fhe Workers'Compensation laws_ Lighting Fiz�ures First 40 ADDRE55 iatal No. �ditionol CITY Tel.No. �ate °pplican� Fixed Appliances Not Over I HP IOTICE TO AhPLICANT: If, after moking thia Certifiea�e of APpM�GM�i f' C` t ��C l aemption, you shoutd become sv6iect to �he Wcrkers' Ra�ge_Heater_D.W._ Compensation provisions of the La6or Code,yau must forth- Oven _Dryer _W.M._ ADDRE -(�, �/ ��� wi�h mmply wilh such provis�ons or this peimit sholl be Top _FAU _W.H._ deemed revoked. CITY �� ���(� Tel.No���(.j � IICEN$ED CONTRACTORS OECLARATION Hood _Fon �O�her_ Disp. .___Room Air Cond. — ���E�� Class�� � I hereby afflrm thaf 1 om licensed under provisions af Chapier 9 REG.NUMBER U (wmmencing with Section 7000�of Dfvision 3 of the Business Power Appo�atus&Lorge Applionces DISTRICT NO. PROCFSSED BY 0. ond Professions Code,aad my license is in full for�e and effect. +� O � ��y//y/����q� ,Q � Size 8 Type HP,KW,KVA,o�KVAR � d '(�ci`o n � € License Number__�'�Lic Class fINAL � /� Up to 7 Incl. � �/�`Z?/C��,� � Ouer 1 to 10 tncl. DA� 3-�U- VALI�ATION � � Conhocror Date ❑ Over t0 l0 50 Incl. FINAL � / W t 1 am exemp��nder Sec. Over 50 fo 100 Inc. BV �--Y �- � B.BP.C.far this reason Over 1W 0 � Z' t pa�e: Services,Swbd.,MCC 8 Ponelboards : 0-200 Amp.Under 6W V � �� ��l;-� 1�. � Signature 201-1000 Amp.Under 6W V ❑ Over IQQO Amp.or Ouer 600 V n s o c . . � � Exemprion for Reg.Maint.Elect. I E 1 1 `_.f: ':, S�NGLE FAMILY Temp.Power Pofe 8 Appur�enances �� �� � HOME OWNER-BUIL�ER DECIARATION Sign with One Bronch Circuit s c• � . � � , �ere6y affirm thar t om exempt from the Co�tmnor's License qdditional Sign Branch Circails , , � ' taw for the fol�owing reason(Section 7031.5, 8usiness and (i Y'.L c-''- ' Professions Godej� " ! ❑ I,as owner of the property,will do the work ond the Misc Conduits 8 Conductors � sirotlure is noi intended or offered for saie(Section Other(See Comp�ete Fee Sthedule)_ � � 7044,Bosiness ond Profeuions Code). � CONSTRUCTION LENDING AGENCV I hereby affirm that there is a conslruclion lending agency for � the performonce of the work for which rhis permir is issued p�RMiT FEE (Sub-7oto1) 3 (Sec.3097,Civ.C.). PLAN CHECKING fEE � Lender's Name PERMIT ISSUING FEE Lender's Address // !certify thoi!hove reod this applicalion ond s�a�e thot ihe 70TAL fEE � above infwmation is ronecL I agree to mmply with all Couniy ordmonces and S�ate laws reg�latinq Eledriml wiring, vnd I hereby outhorize representotives of this Co�nty to enter upon I the ave-mentioned propeHy for inspech p poses. � � SEE REVERSE PQR EXPIANATORY LANGUAGE � Signature of Permittee ��� � � � � � � v� \ � �t� � � �'V G C.f 6� S u �, � � �F \i . � - O � ~ �� � T� \ i N � ... 0} � C � � a �r�S r.. t � d S O w d p"c ..Y•.. l� Q"`r'D `C'O G.C y1 ` ��� r vi v JGin 4:. m S j�p� ✓� @ t � y � b � f C Y � , 1 \ ,�, ! . �O II+O. + .L &c�r m y fG v O 1 \ p �' O �n-q N � ^C O Y S-. 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