HomeMy WebLinkAbout1609A (9) �
WORKERS'COMPFNSATION DECLARATION 76Ab63 ���a, APPLICATION FOIt ELECTRICAL PERMIT �
I hereby nffirm that I have a ceriificnle o(conseN to self CF�BOGG
i�s��re,or a certificote of Wo�kers'Compensatio�Insu�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certifie r.opy thereof(Sec.380Q Lab.C.)
P❑ollcy No.p,_L[,.�t�Company �.�.�r'��� FOR APPUCANT TO FILL IN JOB • �
Certi{ied co is hereb furnished. EACH NO. FEE A�DRESS
PY Y New Residential Bidgs.8 Pools
1 k 2�Famil S Ft. § — $ LOCALITV �U,�, f"`
ertified copy is filed with t e unly building inspeo Y• 9� _
NEAREST �"'
tion department. Multi-family Sq.FL CROSS ST. r,J �fc.�� �
Da1e��Applicpm ` Residentiai Swimming Pools OWNER OR le]
FIRM NAME „� `K. Q ^_�7
CERTIFICATE OF EXEMPTION FROM WORKERS' nnAa Y
� COMPENSATION WSURANCE Outlets:Rec_LigM_Sw._ qpoRE55� 1(j '` '�
This section need not be com leted if the work involved b Firsi 20
�. � P Y Totol No. Additional ❑TY� .11�� �' Tel.No.�'� l�
� the permif is for one hundred dollvrs'[;100)or less.)
I cerfif ihot in fhe erformonce of the work for whi<h ihis PLAN CHECK �
Y P APPLICANT ` ��L � �.>
�permlt is issued,I shail not employ any person in ony mnnner
.so as ro become subjecr to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS �� �` t �
Total No. Additional
CITY � Tel.No.
Data Appliwnt Fixed Appliances Not Over 1 HP PERMIT `
NOTICE TO APPLICANT: If, after making Ihis Ceriifimte of APPtICANT'' .M � ��
Enemption, you should become su6jecl fo ihe Workers' Range_Heater_D.W.—
� Compensation provisions of the Labor Code,you must forth- Oven _Dryer —W.M.� ADDRES i ^ ,�?� ...vL�
with comply with such provisions or this permit sholl be Top _FAU —W.H.— : �
deemed revoked. Hood _Fan _Other_ CITY ��_d Tel.No.� _
� LICENSED CONTRACTORS DECLARATION LICENSE OR
� I hereby affirm that I am licensed under provisions of Chapier 9 Disp. —Room Air Cond. — REG.NUMBER� Class. �
'(commencing with Seciion 7000)of Division 3 of Ihe Business DISTRICT NO. PROCESSED BY a.,,'
I and Professions Code,and my license is in foli force and effect. Pa�+'er Apporatus&Large Appliances ��
I � I y7� � Size 8 Type HP.KW,KVA,or KVAR ( V
I .License N mber ����� Lic.Class_iC�_ Up ta I Ind. FINAI �
� '2,—tl:� Over 1 to 70 ind. DATE yp��DATION �
Controctor r ` Da�e —� pver 10 to 50 Ind.
FINAL [i!
� -❑ I am exempl under Sec. Over 50 to 100 Inc BV a,� {�n,(�A �
� B.RP.C.for ihis reason Over i00 �
I � Dote: Services,Swbd.,MCC&Panel6oards � �:�s e ee�o e�? �
� � 0-200 Amp.Under 600 V
f Signature 201-1000 Amp.Under 600 V
I A ��25,50
� ❑ Over 1000 Amp.or Over 600 V � �• �2.:1.v Q'.�`�
Ezemption for Reg.MainL Elect.
SINGLE FAMILY �Tem Power Pole&A urtenances � � � R
� HOME OWNER-BUILDER DECLARATION P� PP � .C�`•J b
� Sign with One Bronch Circuit
� i t e oy oii ir�n ii�oi i o n exempi irom the Coniracior's license qddi�ional Sign Bronch Circuils
Law for the following reason (Section 7031.5, B�siness and
i Professions Code):
❑ I,as owner of the property,will do�he work ond ihe Misc Conduits&Conductors
structure is not intended or offered for sale(Saction Other(See Comple�e fee Schedule�_ ,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm ihat ihe�e is o consrruction lending agency for
the performance of ihe work for which this permit is issoed PERMIT FEE (Sub-Total) �� �-
(Sec.3097,Civ.C.).
� PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING fEE J' �G
Lender's Address � �
� F'certify that I have read this application and stale thal Ihe TOTAL fEE _1
I above informotion is mrred.I agree lo comply wilh oll County
or inonces and Siate laws reguloting EleUriml wiring,and
he e y oufhorize represenlotives of this County io enfer upon
I ihe ove-menti ty ins�ecrion purposes� e
� y �� SEE REVERSE FOR E%PLANATORY iANGUAGE
Signature of Permiltee Da�e
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