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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 , i �ture of r ilt e � � �7-- � f ate � � � ! 4 � � ! � ! I I � ! 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