HomeMy WebLinkAbout1281A WURKERS'CQMA€NSATION DECIARATION ��� �a�8� p,pp«CATipM FOR ElECTRfCAL PERMIT � I
1 hereby affirm thef I hove a cerlificate of consent to self CE-806G
inswe,or a certiticate of Workers'Compensotion Insurance, CQUNTY QF LOS ANGELES BUILDING AI�D SAFETY
or a certified copy ihereof(Sec.3800,lpb.C.)
POolity No. CompanY POR APPUCANT i0 Nll 1N JOB /�
Certified mpy is hereby furnished. EqCH NO, p� A�DRE55'G �
New Resideniiaf Btdgs.6 Pools
� Certified wpy is filed with the county building inspec- �&2-Family,Sq.FL r�'� _ — 3 LOCAIITY
tion department. Mulli-family$q.F�. — NEARES7
Residen�ial 5wimming Pools
GROSS ST. �'L a..
Dote qppficant owntEu OR
FIRM NPME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec�tight_Sw_� �+��
C6MPENSATION lNSURANCE AO�aESS
(T[�i�aQe►�en naed not 6s compiafad if tl�work Involwd by t� First 20
t{w p�nnil is ior aw kYndred doliara(5100)or lou.) Total No.�i� Additionol CITY i� tel.Nn.
I[erlify Ihat in ihe perfOrmpnte of the work for whicb this PIAN CHKK
rmi�is issued,1 shalt nor em lo on A7R�CAM
Pe p y y person in any monner �i Min fixNres First 2p
so as to became subject to ihe Workers' ompe�sation Laws. 9 9 ApDRE55 1�
' ' �` To�ol No. �-d---- Additional
Date ��Applicant Fixad Appliances Nol Over 1 HP CITY �� Tel.No. ��
NOiICE TO APPLI NT: If, ofter mokin t is Certificate of FERMIT
Exemption, yoo shouid become subject to the Workers' Ronge_Heater_p.W._ 0.PvuCANi
Compenmtian provisions of rhe to6or Code,you most forth• Oven .�pryer _W.M._ ApDRESS ��
wrih camply with such prorisions or this permit shall be Top _FqU —W.H.� �
deemed revoked. Hoad �Fan _,.Other_ C�TY °� ief.No. f�
LICENSED CONTRACTORS DECLARATtON �' tICENSE OR
f hereb oH"am that 1 am licensed under mvisions of Cha ter 9 Disp. _Room Air Cond. S�S 'Z.. Class.
Y P p REG.NUMBER
(commen�ing wilh 5eclion 7000)of Divis�an 3 of the 9usineu power Apparatus 8 large Appliances �ISTRICT NO. PROCESSED 8Y
and P.ofeulons Code,and my license�s in full force and effec�. �
Size&Type HP,KW,KYA,or KVAR �
License Num6er Lic.Class Up io t Incf. fINAI ' y
Over I to 10 Ind. DAFE ��� p� O �
Cantractor pote d VALIDATfON
aOver 10 io 50 Ind. PINAL . �
I am exempt under Sec. Over 50 to 100 Inc, gy W
6.8P.C.for fhis reoson Over 100 L
N
Date: Services,$wbd..MCC 6 Ponelboards � � Y
� m . n er
Signature f-100p Amp. n er G00 V di
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg-Main�.Elect.
SWGLE FAMILV Temp.Power Pole&Appurtenunces � � �� 2 a� a
HOME OWNER-6WlDER DECLARATtON Sign with One Bmnch Circuil �� '
I hare6y affirm fhat I am exempt from the Commctor's ticense �• • • • �z
Addltiono!Si n Bronch Cucvi�s ��
Law for tbe foliowing reoson(Sec�ion 7031.5, Business and g �
Prof ssions Code): � ���a�C'
Misc.Conduffs 8 Condocto�s � � �3 E,5�.
I, ns ownar af ihe property,will do the work and the �� L
ucture is not intended or offered for sale(Section Other(See Complete Fee Schedulej_ �
7044,Business and Professions Code). Q� 2 7�$�
CONSiRUCT10N IEN�ING Af,ENCY '
i hereby affirm that ihere is a mnstruction lending agency for
the performance of the work for whirh tbis permit�s i:sued - pEgM�q��-� -- .� -.__. . ._.._....._(5„a.qorol)----�'� - � ----...
(Sec.3097,Civ.C.). ` f Q -"- ..- . ...
� PU1N CHECI(lNG FfE
Lendei s Name���
(r VERMI7 ISSUfNG FfE �
Lender's Addreu .
1 cerF�fy thal 1}wve read this applicotion and sm�e�hof tbe � TOTAL FEE rd g�
abme information is correct.�agree to comply with oll County
ordinonces and Stote laws reguloting Eleciriml wiring,ond
hare6y auihorize representotives of this Counly to enter upon
the ove-menti n prop for inspeclion purposes. , SEE REVERSE FOR EXPIANATORY LANGUAGE
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