HomeMy WebLinkAbout0767A WORKERS'COMPENSATION DECLARATION �6A663 y�Di9� �App�fCATION FOR ElECTRICAL PERMIT �
I he by'.rffirm that I have a certificote af consent to self C6806G � .
ir�ure,or a certificate of Workers'Compensatio���su�aoce, �a COUNTY OF LOS ANGELES � BUILDING AND SAPETY � �
or a certified copy ihercof(Sec.380D,Lab.C.) � � � �
P❑ol�icy No. Company FON APPLICANT TO FILL IN ��B ,
Certified copy is hereby furnished. New Residential Bid s.&Pools
EACH NO. FEE ADDRESS ( J.
❑ 1&2-Famll S Ft. 5 = S tOCALITY ,,Q .��„ �s.^�
Certified mpy is filed wlih ihe county building inspec- Y� 4� NEAREST ,
tion department. Multi-family Sq.Ft. CROSS SL ��'��
li ' 'Residential5wimmingPoo�s OWNEROR �L�� � , � ��
i Date Applicant � PIRM NAME ��'
� CERTIFICATE Of EXEMPTION FROM WORKER$' ��� /-
COMPENSATION INSURANCE � Outleis:Rec_Light_Sw._ .ADORE55 �y0.4 �!/L�
First 20 �7� � T�
This secfion naed not be com lefed if fhe work involved b � CITY - i.No.
� P y Total No. Additional ���l � '�A
the permil is for one hundred dollan(5700)or less.) P�AN CHEC�e /�,
� I certify ihat in the perfarmance of the:work for which ihis , APPLICANT [.�/ . s` �� -� G' �/C
f.. " permit is issued,I shnll nof employ any person in qny monner
� so as fo become su6jzci to ihe Worker'Compensation Laws. Lighling Fixfures First 20 ADDRESS ��2 / �� / �!
' /// {/ Total No. Additional : CITY • Tel.No. �
�Date�"A licant -� �
PP , Fixed Appliances Not Over 1 HP /r
N�ITICE TO APPLICANT: If, aft r making t is Ce �i ate of A PNLI,CANT . C.�'/ � f=���`
` �nption, you should b'ecome subject fo ihe Workers' �. Range_Heaier_D.W._
�pensation provisions of the la6or Code,you musi forih- Oven _Dryer —W.M.— ADDRESS �.+�� / ��//� L"
j with comply with such provisions or ihis.permit shall be � Top _FAU —W.H.— QTY �.j f, �„!� Tel.No.��J����
� deemed revoked. � Hood —Fqn —Other_
LICENSED CONTRACTORS DECLARATION LICENSE OR
� I hereby affirm ihai I am licensed under provisions of Chapter 9 � � Disp. —Room Air Cond. -- - REG.NUMBER �O 6 � Class.� Q -
(commencing with Seciion 7000)of Division 3 of the Business t;power Apparalus&Large Appliances x DISTRICT NO. PROCESSED BY 9,
and Professions Code,and my license is In full force and effer.t. !�A d. �
- � f/"a� � Size&Type HP,KW,KVA,or KVAR �� � �
C� Lic Class ��`� FINAL
Li[ense Number.• -�.:� Up to 1 ind. �g
� �' DATE
Over 1 to 101nc1. VALIDATION �
�1 Contracto �a}e�--��.: Over 1D to 50 Ind.
y ❑ FINAL y
� I om exempt �er Sec. Over 50 to 100 Inc BY g�W„
8.8P.G for Ihis reason Over 100 »
j , ' �`Services,Swbd.,MCC 3 Panelboards � / �
� �ate: p-200 Amp.Under 600 V , �'� •� ,. �-
� Signature ��f' 201-1000 Amp.Under 600 V !: �1tj�1!N �^��Z o t�l �'��`` �
� Over 1000 Amp.or Over 600 V
$ Exempfion for Reg.Maint Eled. s`,�. .
�y SINGLE FAMILY ' � I I . �
i HOME OWNER-BUILDER DECLARATION �B:7emp.Pcwer Pole&Rppurtenances _ _„`,,::c���}
� ���Sign wilh One 8ranch Circuit - y � m - � �
��,eby offirm thpt i pm exempf from the Controdor's License� #;qddifional Sipn Branch Circuita jl m ti i'
'" "'ie(oiiowing reoson(Sec�i�n:031.5, o�sl���as and �: °� - -
� Professions Code): LI ' .
❑ !,os owner of the property,will do fhe work and the �@pp�Misc Canduils&Conductars � " °�"'r`�
�siructure is not intended or offered for sale (Sedion �,��•Other(See Complete Fee Schedule)-� � „ „ ,. ^„`����
7044,Business and Professions Code). . ��` �
CONSTRUCTION LENDING AGENCY � r� jj/,i ;!�•����'� . �
I hereby affirm ihai there is a construction lending ngency for .�
the performance of the work for which this permit is issued �i�. PERMIT FEE (Sub-Total) `9 U� �
(Sec.3097,Civ.C.). . �
ft,� �?� PLAN CHECKING FEE � 1 U�r�� ���
Lender's Name �/�'� U � / ,�-" �
� .:� PERMIT ISSUING fEE (�� � .
Lender's Addregs =' +��-
I certify iha�I have read this app��cafion and slate that ihe �� �TOTAL FF.E +up.� �._�,��]S�j .
� above informoiion is correct.1 agree to comply with all Couniy �� �
� ordinqnces and Slate laws regulpfing Electrical�wiring, and �
here6y aulhorize representatives of ihis County to enter upon
the a6o -mentioned pr �ry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1
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