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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. 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