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HomeMy WebLinkAbout0548A __. _� _. _. . .__... . _. . WORKERS'COMPENSATION'DECLRI�ATI6N � '����� �-�� 78A6s3 i0/81 � " " � � � • - ��.:. .� � �� ��� .�. .„.,,.�.._, ...,�_..: � CE-SO6G APpLICATION�FOR-EtECTI�TCAL P��I�I�I����`�`"'�""�"���W��� `�.{� I hereby.affirm tha}I have a certificate of consent}o self insure, or a certificate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY LJ copy thereof(Sec.3800.Lab.�C.j ' _. _.. .,. .. ..,.._ .... ... .:.,h.,.......u, ...._...:_ ... _ s��.a�.�:,aw�.-xw�,;;a�.,:u:.;o.. Policy No. �3 Company�NnU-5,/���'� FOR APPLICANT TO FILL IN JOB ❑ Certified Copy is hereby furnished. �w����N/ �� � - ���"� � �� �"'""`"`" ADDRESS� � �� �'��h,e . . , T`j� Neev Residontial BIdQs.&Pools �CH NO FEE Certified copy is filed with the county builtling inspection 1&2-F2mily,Sq.Ft. S — 5 LOCALITY /-��� �� aIt nt. _ , � Multi-family Sq.Ft. � i G`. — NEAREST `, S l�� �n��.�-'�')7f'1`� Resitlentizl Svimmin Pools CROSS ST (/ 7.S � Date ��qpp�icantSJ�+y +�/�,��-� 9 OUJNER OR w�- �J' FIRM NANE /_�"J'� CERTIFICATE OF EXEMPT(Of�CFRONff�16RKERS"��� ���� ����� Outlets:Rec�Light�Sw.1� ��-- � '.nnl� COMPENSATION INSUR�ANCE"'��"` '�� � � � ADDRESS � �}'/� (��'7/� �/� (This section need not be completed if the work inyolved_by the � First 20 ' permit is for one hundred dollars($100)or less.) Total No.�_, Additional � �' CITY �S��,C� ,��' Tel.No. �,��`8{ I certify that in the performance of the vrork for which this permit PLaN CNECK is issued;I Shall not empl0y arry person in any manner So as to f � Q APPLICANT hecome subject to the Workers'Compensation Lavis. ��� ��� Ligh}ing Fixiures First 20 5 A�DRE55 Q Addi!ional '� Applicant Total No._yL_ CITV Tel.No. .ICE TO APPLICANT: If, after �making��this �Certifica}e�of�� FixetlAppliancesNotOver�HP pERN11i l! Exemption,you should become subject to the Workers Compensation R2nge_ Heater_ �.W. _ I APPUCANr r�j ��'`��,��'(,�. provisions of the Labor Code,you must forthv✓ith comply with such Oven_ Dryer_ VJ.M._ ADDRESS �� provisions or this permit shall be tlzemed revoked. Top _ FAU _ W.H._ � LICENSED CONTRACTOR5�DEbLARATIbXI�' �--� Hootl_ Fan _ Other_ �GTY �. �`,]�-� Tel.No����� I hereby affirm thzt I"am'Yicensed�under�provisions��of Chapter 9 uCENSEDR Disp. — Room Air Cond. _ �},�s�p (commencing�vith Section 7000)of Division 3 of the�Business and REG.NUMBEA C�fi'tl Class���j Professions Cotle,and my license is in full�force and eftect.� Pov✓er Apparatus 8 Large Appliances nISiRIC7 ND. PROCESSED BV � ��y. �.J,� Size&Type HP,KW.KVA,or KVAR � 1'�� U��, O License Number � Lic Class � Up to 1 Incl. FINAL J- U ����Cf� Date �� 6 Over 1 to 701nd. DATE O d/� VALIDATION Contractor � ❑ Over 10 tn 50 Incl. FINAL �( � � I am exempt unaer Sea Over 50 to 100 Inc. By W B.&P.C.for this reason Over 700 I a , y Date: Services;Swbd.,NGC&Panelboards � 0-e^DO Amp.Under 600 V . Signa}ure -. 201-1000 Amp,Under 600 U � � Over 1000 Amp.or Over-800 V . Exemption for Req.Maint Elect. � �' � SING�E FAMILY � -""�� � Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION��" - �� ������ Si9n with One 8ranch Circuit '�_�5�I.8 A I hereby affirm that I am exempt from the Contractor's License Law for the foilowing reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Cotle): �o o e e m 2 � _ Misa Gontluits&Conductors ( o���,5,p I,as owner of the property,will do the evork and the structu:e� is not intended or offered for sale(Section 7044.&;siness Oiher(See Gomplete Fee Schedule)_ , 9 ��,j�5 2.5(�� and Professions Code).�� �- o o.Q 7�8 7 CONSTRUCTION CENDING�AG�EN�CY -� � � ' I hereby affirm that there is a construbtion�lending agency for the performance of the�moFk for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Totai) 7 Civ.C.l. PLAN CHECKING FEE � Lender's Name PERMR ISSUING FEE !� Lender's Atltlress ,�, I certify that I have read this application and state thai the above TOTAL FEE GQ` information is correct.I agree to comply with all County ortlinances and State laws regulating Electrical Utiring, and hereby�authorize� - � �- � ���� � �� � � ��� � " � repre5entativeS of this County to enief upon the abov-mentioned - � proper/+y tor inspection�pu"rpos�es/. SEE REVERSE FOR EXPLANATORV CANGUAGE�����-���' "��- ��� ' � � � � � � `:/!� //d4✓","(i'r ��" � Signature ot Permittee Date . �.�.::.. ......:... .;.., ..,.,�...:., ..� �..,��:y.r.... . . ::urr;,w :..,� �;� .; ��� :�a�,s�%�- x��.,..,.._.,�.�,�.y�e-;. � , -- �- -- -- - -- ,. .. . . � .vy � �,, " L. . '�4J �F.�'-�;L� FD- ...trA�a-'`? S ' , ' F- �- .. . �.....__��'� _. � ��.._,�,;: �...�� . . _.r� :`vr tt t n:. �xrmp. ... .,o.,_� ...... . ,._ __._ . _._._. .... . _. ._._{ ..r f� . - e.s�1 �x� C t � 2'r�". 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