HomeMy WebLinkAbout1651A b79RKERS'COMPENSATIONDECLARATION 7sqss3 io/8t qppLICATI�N FOR ELECTRIC�IL PERMIT �
I he."�by affirm that 1 have a certificate of consent to sclf insure, �E-8nr>G
or a certificate of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING A D ETYr.
copy thereof(Sec.3800,Lab. 9 �,,. �
PaIiCY No.�,Q.��P� �?h(� ,�T'r-"(JL� FOR APPLICANT TO FILL iN J06 J -�
❑ �Cerlif'red copy is herehy fumislted. EAGH NO. FEC AODRE55 r •� A� , r �/
� , . New Resitlentiai Bid9s.�Poois — .
!Certified Copy is fiied with th.cqunly building inspection 1&2-Family,Sq.Ft. 5 — $ �OCALITY .�
:de ar 0nt / � .\EtiFESi
� Multi-tarriily Sq.Ff.
Date � �� � Aesitlential Swimminr Pool,s caoss ST W f" �
Applj��nt � OWNER OR .�-Y
FIIiM NAME _Z�
' CERTIFICATE OF EXEMPTION FROM WORKERS' Outleis:Rec—Li�hl_Sw.— ���
COUPENSATIONINSURANCE ACOFESS ��} Ljp'�� �3�L.
(This section need not be completed if the work involvetl 6y the First 20 �� �
Tmal No. Additianai CITV `-�,
permit is for one huntlred dallars{$700�or less.) � � �
I Certlfy that in the porformance M the work for which this permit PLAN CHECK
�IS�i55Ued,I 5hdll nOf P.m fo an APPLICANT
p y y persan in any manner so as to .
hecome subject to the Workers'Compensation Laws. Lightin9 Fixtures Pirst 20 - ADDRESS �
� Total No. Additional '
Aato Applicant E CITY Tel.No.
'NOTICE TO APPLICANT: !f, after makint7 this Cer[iiicate of � Fixed Appliances Not Over 1 HP ` pehtMii ("7,[y�`
!Exemptioq you SFrould become subjechto the Workers•'Compensation ...i Range�Heater_ O.W. _ � ArPUCnNT r r�r��-� �,�
rv%ovisicr�a ll.`.h2 LabCr.Ccde,i`cc r.:ys?fo::�::•i?!:cer,,pl,�adrn s��ch � pvp i.. Dryer WM._ ADDRE55 �{_3 S �d� F�t.,�i1�n.CJ/N
.iprovisions or this permit shall be Aesmed revol<ed .� Top _ FAU _ W.H._ �' '
� LICENSED CON7RACTORS DGCLARA�ON i i CITY �� Tel .
;1 here6 affirm�t at I am licensetl under � Nood— Fan _ Other_
Y h provisi ns ol Chapter 9 b Dis _�Room Alr ConA. — uCENse or;�
�(commencing wiih Section 7000)of Division 3�the Business and �i . P' REG.NUnneEN"�---•--�-��^..-..�----�.--^-.�-.-Gi�s
,Professions Code,antl my license is id full fo�and effect ; .Power Appnretus&Large Appliancas DISTroCr N<7, / PROCE55Eo BY �
( i Sizc&Type HP,KW,KVA,or KVAR ' /� Qa
��Liccnse Number �a Cl:uss � Up to 1 IncL � FINAL / �i � v
i� � ' S Over I to 10 IncL 1 DATE / y
'Contractor � Date r �� t �( ,� U VALIDATION � �
+❑ � Ovcr 10 to 60 Incl. � F;NA�
I am exempt under Sec. / {� .Over 5U to 100 Inc. Siii By ✓ `U
� 6.8PC.lor this reason � € -Ovcr 700 � _ �l� p��,
� i/ � Scrvices.Swbd..MCC R PanelhoarAs � �
� Dala � 0-2U0 Amp,Undcr G00 V �°
' Signaturc ' 201-1000 Amp.Under 600 V � -
� ;❑ � Ovor 100�Amp.or Ovcr 600 V y
Exe,mp[ion for R�Meint.Elec[. �� •
� ; �
SINGLE FAMILV ,Temp.Power Polc Z ApUurtenances � t j`��1 ,,'� (�,��,� A
HOME OWNER-OUILDER DECLARATION q �
�I hereby affirm that I am exemp;from;hc Contractor's License Law � Sign wifh One Branch Circuit
� for tho toliowing reason(Section 7�3t.5,Business ana F'mfeseluns �� /+dd�tional Sign Branch Circuits �i F, ° m ° '��
codc>: t � J �, a�;:�Q
�� Misa�Conduits&Conductors
I,as owncr of the property,will do the work and the structure �
i is npt intentled or oiFered for sale(Ser,tion 7044,Busine.ss �Other(Soc C�mpletc Fee Schedule)� ° °`��J.S�r"a.
( � and P�o�essions Code). _ � 0 9.1 4-�8 7
t
CON$TRUCTION LENDING AGENCY �
� ��I he{eby aftirm thRt there is a construclion lending apency for th�
�pertormance of Ihe work for which this Uermit is issued(Sec.3097, :� PERMIT FEE �Sub-Totol)
c��.c.�. 1J
���
� � � NLAN CHEGKING FEE , ,
�.�ender's Name �'. `
� PEf?MIfISSUINGFCE /O S�
Lender's Address �, �
I certify that i hava read ihis a�plication and state tha[the ahove k� T07AL FEE �'�
.information is correct.I agree to comply with all County ordinances �
�an�1.-3tafe la s regulating Electrical w'�nng, and hereby aidhorize �,
prosent�-p�s o�,,jhis C�unty to enter upon thc above-mentioned �. �
�P OP9 orvitl mF p����SP. r � i:
'; � `,�'�� � G'�/.'� � 'i"'� . u SEE REVERSE FOR EXPLANATOHY LANGUAGE ,
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