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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 � �� �� , ignourE�ofP ittee Date �;� . � . , � i ' ; � ' � i ' ; 1 '� . i i ' `� � t , � pi� �} , L ^tit � G X�'�''C i� v ! O� 2' � �z C �� �'1� -a�y t , � � -a ' 9 .� m �' Ci,, Z �� {} „"°a 1 ! � ' S � � f� '� �' O � n�O ' I i O Z 1 1i C d Q i b � 1 � 7� 1 � -1 � rn 1 N t} ' � } , R7 [J � , � �, 1 � � � � � �, ! � � 1 x � 1 i 1� ' c � '. 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