HomeMy WebLinkAbout1719A (10) WORKERS'COMPENSATIONDECLARATION 76A663 ,o,e, qppLICATION FOR ELECTRICAL PERMIT {�
I hereby alfirm Ihat 1 have a certificate of consent to self insure, GE-BosG
or a cer�7icate of Workers Compensztion Insurance,or a cerflied COUNTY OF LOS ANGELES BUILDING AND SAFETY ��
copy there f c.3800.Lab.C.) /y�
POlicyNO. J�Cpmpany/��VS����`�/�_ FOflAPPUCANTTOFlLLIN JOB �j /7
� N/J EAC td0. FEE A�DRESS Q D �S. SL N/� ✓ y
Certilied copy is hereby fumished. � New Residenti�l BICgs.8 Pa
� 1 8 2-Famii S Ft.� 5 — 5 LOCALITY L/ �'� �
Ceriilied copy is filed with the county 6uilding inspection y� Q�
,�m L ra�n�-+amay sq.Fc — cRoss sr. O /�7C�
DZte��� � App!iCdnt ReSiCen!i:11 Swimming Poo!s plvuEfi Ofl
_ , � FIRM NhME �
CERTIFICATE OF EXEh7PTIDN FROM WORKERS' putlets Rec—Ligh[—Sw.— rt�mL // ij
COMPENSATION INSURANCE � ADDFESS�
(Thia cectbn need not be cornpleled if the work Involved by the First 20
pBrmit is for one hundred dollara�5100)or lecs.) , Totol No. Addition2l qTY 5 �' �j� I.No��. QQ
I certify�hat in Ihe pertormanCe of the t•mrk for which this permit - qp���{�K -
is issue4 I shall rwt emptoy arry person in zrry manner so as to
become subject to the 1"lorkers'Compensation Lzvrs. L'ghling FixNres First 20 � � ADDRESS � � -� �
Total No. Add4ional CITY - - Tel.No.
Dale ApplicaM Fixed Appllances Not Ovzr 1 HP pEHMIf /�-7
NOTICE- TO APPLICANT: If, after making this Certif'�cate of nrrucarrr�� � C �/� G
ExemGiion,you shwld 6ecome sub;ect to Ihe tVorkers'Compensation Rance_Heater_ D.VJ. _ _
prwisions ot the Labor Code,you mu�t torthwith comply wilh such Oven_ Drycr_ W M._ ADDRESS •Q• x ��
provisipng or th�s peimit shz!I he deemod revek=d. Top. _FAU _W.H._ T/ �v G[��/�`_
CITY � Tel.NoJ7 VYCf/
LICENSED CONTRACTORS DECLARATION Hood— Fan _ Other_ /v
I hereby affirm that 1 xm licensed under provisions of Chapter 9 Disp. —fioom Air Cond. _ uFENSE On A..�b3 . ,qass`'�
(COmmenciry Wilh SeCtion 7000)Of Division 3 0(Ihe 6uSines3 2ntl R_G NUVCEFi V(/O
Professions Code,and my license is in full force and effecL Power Apparotus&Large App!i�nces D:STRICT NO. PROCESSED OV �
� ('�r� ^ � Size&Type HP,KW,KVA,or KVAR D `,`0.`o!� �
� License Number f���v Lic.Class � Up to 1 Incl. FlNAL
�, f..�./ C�� Over 1 to 70 Incl. DATE l� Z tJ� YALIOATION �
I
CoMractor��-�� yT` �s!e FlNAL
I � Ovcr 70 to 50 Incl. U
! ❑ I am exempt under Sec. . Over 50 to 100 Inc. gy /�--- .
� OvPr 100 �"' �'
� BSP.C.for this reason N
Services,Swbd„A!CC 8 Panelbo2rds� ► Z
- Date: 0-200 Amp.Under 600 V
Siqnature 201-1000 Amp.Under 600 V � '
� � - Over 1000 Amp.or Over 600 V ' � 7����7
� Exemp!ion to�Reg.MainL EIecL � � � -
ir • + �
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� � SINGLE FAMILY Temp.Power Pole S Appurlenances
HOME ONl1'dER-BUIL�ER DECLARATION Sign with One Branch Circuit � ° � '1 G'i li
I hereby atlirm that I am exempt fmm the ConV2ctor's License Lew Addilional Sign Branch CirCuils
for the folla,virg reason(Section 7031.5,Business and Pmfessions -- - - - , , ,.,��,—r•,�
Code�:
❑ I,as owner oi lhe property,will do the vrork and the structure M'sC.Conduils 8 Conductors
C . C)—i3�i
is no[int=rr�?d or offered for saie�Section 7044,Business Other(See Complete Fce Schedule)_ ,
and Professions Cod=1.
CONSTRUCTION LENDING AGEPJCY ��
I heleby affirm that theie is a construction Iendirg 2gency lor the ��
performance of the work for which this permit is issued ISeC.3097, PERMIT FEE �� � (Sub-Totap � � �-
Civ.C.).
PLAN CHECKING FEE_ _ .. . .. .. . . . . _ _ . . '
Lender's Name
PERMIT ISSUING FEE f O .
Lendeis Address
I certify that I have read lhis applicalion and stale lhat the above TOTAL FEE a�g'v . . . , . -
Information is correct.I a9ree to comply wilh all County ordinances ,
and State laws re9ulating Elechical winng,2nd hereby authorize �
�0^Csentatives of this County to enter upon the above-mentioned .
p for inspection�se� j!/� , SEE REVERSE FOR E%PLANATORY.LANGUAGE .
(f�
Signature of Permittee Date
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