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HomeMy WebLinkAbout1482A WORKERS'COMPENSATIONDECLARATION 76A663 10ia� �����C�,TIQ�IV FOR �LECTRICAL PERMIT � I hereby affirm that I have a certificate of consent to self insurc, CE-ao6G or a certificate of Workers'Compensation Insurance,or a ccrtified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.38QyL�yb.C.) PoliCy No. } � �Comparry FOR APPLICANT TD FILL IN �ng r// ��'�@q��,�i �� � EACH h0. FEE aooNEss �f s v Certifietl copy is hereby furnished. New Residential Bltlqs.8 Pools $ _ $ LOCALITY`��/��ffQrVy � �� �-0ertifietl copy is tiled with the county 6uilding inspection 1&2-Family,Sq.FL _ f/� ) /� �department. � Multi-family Sq.Ft. CROSs ST.�H/"SC�C����� Date � �Applicant ' Resitlential Swimminq Pools pwNeR OR �/^''�' a FlRM NAME /vGJ� /' � .CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—L'gh!_Sw.— MAIL `^�� , COMPENSATION INSURANCE . nuoRess �J/�y .�This section need not be completetl if the work involvetl by the First 20 CITY Tel.No. -,;permit is for one hundred dollars($1W�or less.) Total No. Additional ��'` ��:I certify that in ihe performar�ce of the work for which this permit nPPLICANT K � (r'J ,l(J� ,is issued,I shall not employ.arry person in�ny manper so as to 6ecome sublEct to the Workers'Co ation Laws � Liyh[ing Fixtures First 20 �AD�RE55 � L Addi[ional y ���,�� Total No. GTY Tel.No. Date 1��APPlican ����� Fixed Appliances Not Over 1 IiP f pERMII / :NOTICE TO APPLICANT: If, after making this Ccrti ate of nPPucANi� � - L��� ~ � �.�Exemption,you ghould become subject to the Worke�s'Gompensation Range_ Heater_ D.W. _ :,pravisions�of The.Labor Code,you must forihwith comply with such Oven _ Dryer_ W.M._ ADDRESS��`"j� ���� '��'�% ��provisions or this permit shall be deemed revoked. � . Top — PAU _ W.H._ . GTY 7� ��� �� I.No.��j��� LICENSED CANTRACTOf3S DECLARATION Hood— Fan _ Other— =1 hereb a�tirm that I am licenscd undcr ovisians of Chaptrr 3 uCENSE on 4 . � Y P� DisP. — Room Air Cond. — ✓� Class. � �commencing with Section 7000)of�ivision 3 of the Business and REG.NUM[3ER �✓ � .w�- �- ? ProPossions Code,and my license is in full force and eifect. . power Apparatus&Large Appliances oISTRICT No�.' CESS- 6Y � Size&Type HP,KW,KVA,or KVAR r-._,.�`" p License Num6er Lic.Class � Up[0 1 IneL FlNAL � Over 1 to 101nc1. �ArE �� �-/7 VALIDATION �' Contractor Date ��'� " '����r � ❑ � Over 10 to 50 Incl. � � F- FINAL I.am exempt under Sec. , Ovor.50 to.1.00 Inc. : BY � ./'`:-.�-________ __ W L_ , B.&P.C.for this reason Ovei 100 � „ Services.Swbd.,MCC&Panelboards � �K � � Date: 0-200 Rmp.Under 600 V � Si9nature 201-1000 Amp.Undcr 600 V � � ❑ Qver tUUO Amp.or Ovcr 600 V Exemption for Re9.Mnint Elect. �� �j n•,�M1 SINGLc FAMILI' ':.f,TcmD.P:,•wGr Pcic&Appur«enarces ' � --. :.=,. � � HOME OWNER-BUILDER DECLARATION �jl Sign vaith One Branch Gircuit ' {+° �' ° ° 6 L � I hereby affirm that I am exempt from the Contractor's License Law 1 � , , . .. , .„,., . , u,,. .,.. .. ._ ... °a Addilional Sign Branch Circuits i _ ( n i�� _,(`. ,Coticl� '.. � I,as owner of ihe property,�mill Ao the work and thc structure '� Misa Conciuits&Conductors j � �" `'���'.�r'i� �is not intended or otfered for sale.(Section 7044,Busin�ss # Othr.r(See Complete Fee SchedWe) , o^ and Professions Code). �9,�ri'-�u tj CONSTRUCTION LENDING AGENCY � � I hereby aifirm that there is a conshuction lendiny�agency for the� - � purFormance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Su6-TotaU 'Civ.C.). .' � PLAN GFIECKING��E ,/ ,p'��9 j Lender's Name frF1 � ��6�4g �(✓J`� �1(/�✓� PERMIT ISSUING�EE (V ,� � � Lendcr's Address TOTAL FEE �S�� �!'/'�'/•�1�V�'. �/�� �� I certify that I have read this apPlication e�nd stato lh�t thP above �infarmatian is conect.1 aqiee lo Comply with all Caunty ordinanccs � ..� ��',fj and Siate laws rec�ulating Electrical wiring,�and here6y authorize //%js (��'��''��, . � representatives of this County to enter upon thc above-mentioned s,���� "'�f�� prop for inspoclion purposes. 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