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HomeMy WebLinkAbout1440A (8) „WORKERS'COMPENSATION DECLARATION �E 8 6� '�'�' APPLICATION FOR ELECTRICAL PERMIT ,� � �-I hereby af(irm tha� I hove a certifiwte of consent to self insure,or o certifimta of Workers'Compensation I�su�ance, COUNTY OF LOS ANGELES BU�LDING AND SAFETY ��+ � or a certified copy rhereof(Sec 3800,Lnb.C.) P❑olicy No.`�'I o�mpany�/�r"���L�l�[�"�.�` FOR APPLICANT TO FILL IN 10g Certified copy is hereby fumished. ���' New Residenlial Bldgs.E � EACH NO. FEE ADDRESS �,J•�A�?,�� .7 :,%�� � g ( _ g �LOCALITY� /_r ' _ ��'” '� Certified copy is filed with the county building inspec- 1 8 2-Family,Sq.Ft.� � �� w-� e artment. Multi-family Sq.R. NEAREST {° Residential Swimmin Pools CRO55 ST. ,( Date��� � Applimn(� '�a ' �� 9 OWNEROR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Li ht_Sw._ MAII ,� " ' � � COMPENSATION INSURANCE 9 ADDRESS ,�'�1 ' �'�S+�,K� _ ''�. � This sec+ion need nof be com lefed if�he work involved b Firsi 20 � P Y Total Na. Additional CITY �F.� Tal.No. fha permit is for one hundred dollora(5100)or leas.) I cenif that in ihe erformance af ihe work for which this PLAN CHECK Y P APPLICANT permit is issued,I shpll no�employ any person in pny manner so as to become subject to the Workers'Compensation Laws. Lighting Pixtures First 20 ADDRESS Total No. F+dditional CITY Tel.No. Date Applicant Fiaed Appliances Not Over 1 HP PERMI7 )� � N� �E TO APPLICANT: If, ofter mak�ng rhis Cerufka�e of APPLICANT�r ��'y� � , ' �tion, you should become s�bjecl ro the Workers' Range_Heater_D,W.— ! ��r�,.,a.,.^.sa��...,r..��;���nn5 nF�ho I..L....('.,.le y�,�mu«{.,r�h_ n„e„ —n.;,e. W.M . Al1nRFSS' i\ M�n .�f ith tomply wifh such provisions or ihis permit shal) be Top _FAU —W.H.— 4 deemed revoked Hood —Fan _Othe�_ CITY� Tel No. LICENSED CONTRACTORS DECLARATION UCENSE OR / {� f �hereby affirm ihot I om litensed under provisions of Chopter 9 Disp. —Room Air Cond. — REG.NUMBER` p Ciass.C� � � (mmmencing wilh Section 7000)of Division 3 of ihe Business DISTRICT NO. PRDCESSED BY Lt.� � Power Apparptus&Large Appliqnces and Professions Code,and my license is in full force and e$ecl. //� � f �y ,�,o� Size&Type HP,KW,KVA,or KVAR �'' � License Number V✓ Lic.Class� J d Up to 1 Ind. FINAL � +. � Contractor S�(w Z-�� �`'TT�Date � '7� � � Over 1 to 10 Ind. DATE i y�'���� YALIDATION J � ❑ Over 10 io 50 Incl. FINAL p `u � I am ezempl under Sec. Over 50 to 100 Inc. BY x _ ,. � � B.&P.C.for Ihis reason Over lOD ��v G Date: Servicas,Swbd.,MCC&Panelboards � � 0-200 Amp.Under 600 V � Signature 201-IODO Amp.Under 600 V 3 � Over 1000 Amp.or Over 600 V f Enemption for Reg.Maint.Elect. '`-,� ��O A SSINGIE FAMILY Temp.Power Pole&Apportenances � � HOME-OWNER-BUILDER DECLARATION Sign with One Branch Circuit �-'' � � e A� �••eby affirm that I am exempt from the Contractor's License ��������i�ol'i n 3ronch Circuits � �4e for the following reason (Secfion 7031.5, Business and 'g � 8 m£j�,v Q � ProfessionsCode): - � s � � Misc.Conduits 8 Condudors y � �£��^�J I,as owner of ihe property,will do ihe work ond the �j(�� �_g'7 strudure �s not intended or offered for sale (Section Other(See Complete fee Schedule)— , � 7044,Business and ProFessions Code). � CONSTRUCTION LENDING AGENCY � I herehy affirm ihat there is a consiruction lending ogency for fhe performance of the work for which fhis permif is issued PERMIT FEE (Sub-Total) � (Sec.3097,Civ.C.). PLAN CHECKING FEE � Lender's Name � PERMIT ISSUING FEE �� ' Lender's Address � I certify that I have read this application and srare that the TOTAL FEE �� above informotion is correct.I ogree to comply with all County ordinances and State laws reguloting Eledrical wiring,ond ! hereby authori>e represenlntives of this County to enter upon � the e-mentioned property for inspec�ion pur oses SEE REVERSE FOR EXPLANATORY LANGUAGE � � � �-,c� ��v/��� � Si�neture of 7ermittee Daie E ' ( ! i " 3 !. i ; � � � .. ; , i ; � . ; , ( 1 f j } ! . j � . i � � } $ ; f � � € i t ' � � ^ ,i ', i - ' '- . ; � } 4 ¢ � € � t � ; � - i '' k � " � � . � . ' i � , ' i . � ! � , z , ! , � 1 3 � � � ! i j � , i .. � i . � : ' Y : � C ' . ' i � ; i '; i k ' ! ' , ' ".. . � j i } ' ' • . . . . 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