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HomeMy WebLinkAbout0844A � WORKERS'COMPENSATION DECLARATION �'Zo-oow�Pwaia� APp��CAT10N FOR ELECTRICAL P.ERMIT � IbPb63 I hereby affirm thot 1 have a cen`rfimte of consent to self CF.-8�5G � insure,or a certificate of Workers'Compensation Ins�rance, CO.UNTY OF LOS ANGELES DEPT.OF PUBUC WORKS + or a certified copy there f(Sec.3800,�La .C!.,.) > � � Policy No�Company,T'���//�.YI�C. fOR APPtICANT i0 FIEACH NO. FEE DDRE55 7 / �C �Certified copy is hereby furnished. New Residentiol Bldgs.&Pools � �ertified capy is filed with the coumy building inspec- 1&2-Family,Sq.Ft. $ _ $ ��CA��TY O��h � fion depariment. M�Iti-family Sq.R. NEARES7 f� � �� �����LJ�� CRO55 ST. Dote v�" L2L—A licpnf Residential Swimming Pools OWNER OR PP FIRM NAME ,lT�C= CERTIFICATE OF EXEMPTION FROM WORKER$' Outlets:Rec �—Ligh1_Sw._ �'�� � �f COMPENSATION INSURANCE ADDRE55_ SI � First 20 QTY - ��-s� Tel.No.� � (This seclion need nof 6e complefed if the work iovolved by Total No. Additional '�"lC� fhe permit is for one h�ndred dollars(57D0)or lass.) RLAN CHECK I certify Ihal in 1he performance of ihe work for which this APPUCaNT 1 i��� .� �-'�' permit is issued,I sholl not employ any person in any manner ��ghfing Fixtures Plrsf 20 AD�RESS y ,// K/� so as to become subiect to the Workers'Campensation Laws. S� d�'.,�fY Additional � Total No. QTY � : . �� el.No. J J- Date Applimnt Fixed Appliances Not Over 1 HP PERnniT �'y � NOTICE TO APPLICANT: If, affer making ihis Certificate of APPUCATION -)'?/��Afr� C� �� Exemption, yo� should become su6jecl to the Workers' Range— Heater—D.W.— r ICompensation provisions of the Lahor Code,you m�st forih- Oven _— Dryer —W.M.— ADDRE55 i �with comply Ih suth provisions or ihis permit shall be Top — FAU —W.H.— � deemed revoked. � Hood — Fan —Other— CITY Tel.No. 'i - - . IfCENSED CONTRACTORS DECLARATION- � - Disp. — Room Air Cond. — ucENSE OR - �I here6y affirm ihat I am licensed under pro4isions of Chapter 9 REG.NUMBER �L4 � Class. � '(mmmencing with Section 700D)of Division 3 of the Business Power Apparatus&Larqe Appliances DISTRICT NO. PROCESSED,&Y a and Professions Code,and my license is in tull force and effeci. �� � �l� /� Size 8 Type HP,KW,KVA,or KVAR � � �l..�, I License Number "������ Lic.Class�_..L_ Up to 1 Ind. F�NA� ��7� U DATE ����i/ � � ���C� /�� ^�� Over 1 to 10 Incl. U�—_ VALIDATION 0 Coniractor �� Date Over 10 ro 50 Ind. V ❑ FINAL � I am exempt under Sec. Over 50 to 100 Inc. BY '��y_,1 a Over 100 B.BP.C.for this reason .(A dervices,Sw6d.,MCC&Panelboards : � z � Date: 0-200 Amp.Under 600 V � Signature 201-1000 Amp.Under 600 V O Over 7000 Amp.or Over 600 V i Exemption for Reg.Maini.Elect. / � , SINGLE fAMiLY : Temp.Power Pole 8 Appurtenances / HOME OWNER-BUILDER DECLARATION S `-Sign with One Branch Circuit � I hereby affirm�ha�I am exempt from ihe Contractar's License � �Law for the following reason (Seclion 7031.5, Business and Hdoiiiona�Sign o�anci�Cirwita � Professians Code): , �'„3{,� �p�'�'S �, d �Q�� u ��•. . Misc.Conduits&Conducfors `� ❑I,as owner of the property, will do the work and Ihe ' �!�,.� ° � ,.G siructure is not imended or offered for sale(Seciion 7044, ; � Other(See Complete Fee Schedule)—' 8usiness and Professions Code�. - , ' a � � �s-�, .:�l�i CONSTRUCTION IENDING AGENCY � � I hereby affirm that there is a construction lending agency for ' �O �' � � v�J(,?i 'ihe performance of the work for which this permit is issued �, PERMIT FEE (Sub-Total) (Sec.3097,Civ.C.). �t'•,� j ""t:'� ' . PLAN CHECKING FEE Lender's Name ' � pERMIT ISSUING FEE � � Lender's Address _ I certify that I have read ihis application and state Iha�ihe � TOTAL FEE - i above information is correU.I agree to comply with all Counry .. �o�-� , Iordinances and State laws regulaling Electrical wiring,and � / I hereby authorize representatives of this Covniy to enter upon . fhe above-mentioned pro erty for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE � � /, I . 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