HomeMy WebLinkAbout0843A II WORKERS'COMPENSATION DECLARATION so-oowoPw3ia� APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm ihat I ha�',:o cert�ficate of consem to self cee�
� insure,or a certifica�e of Workers'i:ompensation Ins�rance, . � � UNTY OF LOS ANGELES � DEPT.OF PUBLIC WORKS
or a certifi d.opy thereof(Sec.3800,L b�C.) � �j
Policy No ��Company�i;� FOR APPLICANT TO FILL IN JOB
�Certified copy is hereby fumished. New Residential 81dgs.&Pools EACH NQ FEE
ADDRE55 �l
(}Z(,Cerfified copy is filed with ihe county 6uilding insper 1 8 2-Family,Sq.Ft $ — $ LOCALITY �
� «=�tion department. M�Ni-family Sq.Ft. — NenkeSi
�} CROSS ST �
,s� ✓[,�n / Residenlial Swimming Pools '
�ate�_Applicani /�/✓�� � OWNER O
I 'F�I AM NAME � eS�LiT.F,9 '� �/j,�j..
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlefs:Rec_Liqhl_Sw._
COMPENSATION INSURANCE ADDRES�� (,(.,1t S%� �
(This secMlon need not be completed if the work involved b first 20
Y Total No. Additional ��TY �,f'j /��'� Tel.No. d
fhe permiT is for one hundre(1 dollors�(j100)ar Iea6.) � pLqN CHECK
I cenify that in the performance of the work for which this APPLICANT
� permif is issued,I sholl nof employ any person in ony manner
so as to become subjett lo ihe Workers'Compensation Lows. Lighting Fix�ures firsl 20 ADDRE55
Additional
Date Applimnt Total No. CITY Tel.No.
� Fixed Applipnces No�Over 1 HP PERMIT � /f A
NOTICE TO APPLICANT: If, afler making ihis Certificate of APpLICATION
Exemption, you should become s�bject to the Workers' Range— Heater—D.W. _ 1-C� �-I�1' .�'�--�'
Compensation provisions of the Labor Code,you must forth- Oven _ Dryer —W.M.— ADDRESS;j f� �.. 5� �
wi�h comply with such provisions or ihis permit shall be
�deemed revoked. Tap —FAII --W.H.—
I . LICENSED CONTRACTORS DECLARATION Hood —fan —Other_ ��T �-y �} Tel.No. ° ..! 'r
� , LICENSE OR
�Disp. _Room Air Cond. _ r Class. �d
I hereby affirm fhat I am Ilcensed under provisions of Chopler 9. REG.NUM6ER � /L� >K..7
(commencing with Section 700D)of Division 3 of ihe Business� Power Apparatus&Large Appliances DISTRICT NO. PROCESSED 8Y Y
'ond Professions Code,and my license is in full forca and effeti.��, /� i Q
� Size 8 Type HP,KW,KVA,or KVAR �
License Number � Lic.Class�. Up fo 1 IncL FINAL � . V
y�-�`_�yr,� . Over 1 to IO lnd. DAiE /' VALIDATION � �
Coniracto Date Over 10 l0 50 Intl. / V� � �
� FINAL �
I am ezempt vnder Sec. Over 5p�o 1001nc. BY ; W
B.&P.C.for this reason Over 100 __ '`��-�- •. a
;Services,Swbd.,MCC&Panelboords � � �
Date: 0-200 Amp.Under 600 V , Z
Signature 201-1000 Amp.Under 6p0 V
� O Over 1000 Amp,or Over 600 Y _
Exemp�ion for Reg.Mainc Elect.
� � SINC>LE FAMILY ♦ �
HOME OWNER-BUILDER OECLARATION ��iemp.Power Poie&Appurienances
� j Sign with One Branch Circuit
� I hereby affirm ihat I am exempt from�he Cont�actor's license�'� .
Inu,Fn.�I,e F..II.....:.........�,...�c.....:,...�n�i c o....:_"'"� �Ar�r�ifinnnl Sinn Rrnnrh f irri�itc
__.. ._. ..._.,...,,.....y..,.........�.....�....�.......... ....�iii�..a uiiu .. - - _ _ _
Professions Code: �
) :. a�;C;�I.'_'.F�, -
❑I,os owner of the property, will do the work ond ihe `Misc.Conduits&Conductors �
� structure is not intended or offered for sale�Section 7044, 'Other(See Complete Fee Schedule� , f:`'� ° " " `C
Business ond Profewions Code). � f <t t;G y 5(, .
CONSTRUCTION LENDWG AGENCY '
I hereby affirm that ihere is a consiruUion iending agency for��� W �, �s j��'(��, � ,
the performance of the work for which ihis permit is issued PERMIT FEE (Sub-Total)
(Sec 3097,Civ,C.). ��.! 1 "�'��
PLAN CHECKING FEE .
Lender's Name i
. PERMIi ISSUING FEE �� �('� �
Lender's Address
I cerlify thot I have read ihis applimtion and state thot ihe T�TAL FEE �����
above information is corrett.I agree ro comply wlih all County • �
ordinonces and Sta�e laws regulating Electrical wiring, and . �
� hereby authorize representatives of ihis County�o enter upon �
� ihe above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�i �t.�.�2z,¢� �.c.�cve� ���-�d✓
IS g�re of PermiHee Date �s
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