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HomeMy WebLinkAbout8008AWORKERS' COMPENSATION DECLARATION i hereby affirm that I have a certificote of consent to self insure, or o certificote of Workers' Compensation Insurance, or a certified copy thereof(Sec. 3800, Lab. C.) 20{5 O Policy No.o'), 9C) CompanylA 12 rt 1_1ai(14. Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. /^ Date A-Z_N' AppliconLZAPZ4. 1St i,,etTP c CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be completed if the work Involved by the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Dale Applicant ICE TO APPLICANT: If, after making this Certificate of prion, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby offirm that I am licensed under provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number - tic. Class C 10 Contractok4VPv ll{I f -LEL` -1. DateA Zasa u I am exempt under Sec. B.&P.C. for this reason Data: Exemption for Reg. Moint. Elect. SINGLE FAMILY HOME OWNER -BUILDER DECLARATION i}by affirm that I am exempt from the Contractor's License La.. for the following reason (Section 7031.5, Business and Professions Code): I, as owner of the property, will do the work andthe structure is not intended or offered for sole (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State lows regulating Electrical wiring, and hereby authorize representatives of this County to enter upon Ihf o ve-menlione operly for inspeclio urpo es. ure Date CE806r, APPLICATION FOR ELECTRICAL PERMIT 2 A4, COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN JOB foul_ EACH NO. FEE ADDRESS New Residential Bldgs. 8 Pool LOCALITY LC -;r1 -Z,91& 2 -Family, Sq. Ft. S — s I I 'OirJ-'(Vi Ate- Multifamily Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. OWNER OR (( FIRM NAME Outlets: Rec_Light_Sw._M%L ADDRESS First 20 Total No. Additional CITY C C>—TC,1P_ Tel. No.re%-]_) Lighting Fixtures First 20 Total No. Additional Fixed Appliances Not Over 1 His Range_ Heater—D.W. Oven —Dryer _ W.M. — Top — FAU _ W.H. — Hood _ Fan _ Other_ Disp. _ Room Air Cond. — Power Apparatus & Large Appliances Size & Type HP, KW, KVA, or KVAR Up to 1 Incl.' Over 1 to 10 Inc[. Over 10 to 50 Incl. Over 50 to 100 Inc. Over 100 Services, Swbd., MCC & Ponetboords 0 - 200 Amp. Under 600 V 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V Temp. Power Pole & Appurtenances Sign with One Branch Circuit Additional Sign Branch Circuits Misc. Conduits & Conductors Other (See Complete Fee Schedule)— PERMIT FEE (Sub -Tocol) IC]s PLAN CHECKING FEE -- - PERMIT ISSUING FEE (Q TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE ADDRESS CITY Tel. No. PERMITAPPLICAN ( ] ADDRESS L..-'-Tt_r DISTRICT NO. rU FINALDATE /S ip FINAL J 0. PROCESSED BY A, O U VALIDATION cc O UuaCLN ' noose I e s e •2 1 2646 e^126 41.63 05.06-87 cn Is 903 e k 2 0n k \ 2 z cn Is 2/il,,,, §2§e[r tfR3r. 2a{{\.\&E/Q\[}2§/`/)/ CLr M,:,=Ea= B&m;iƒ4^0'< 2©§®_ k}%^\ƒ2\ƒE{ AC°0-e :keZ' eEz%%)o®% ¥© -°p em,eE#/ /=)ƒ(°E((§[(2 zI$- n 7c% &nEs7&I-©\,,o,na062©S n{`fF, CD o-k`0. Ro rl kjE a}f 0227|® ](}Em(\)% 5 Ira §/|) 0 0E{, 2 k k 0n 2 z 0 G d m Clz 2/il,,,, §2§e[r tfR3r. 2a{{\.\&E/Q\[}2§/`/)/ CLr M,:,=Ea= B&m;iƒ4^0'< 2©§®_ k}%^\ƒ2\ƒE{ AC°0-e :keZ' eEz%%)o®% ¥© -°p em,eE#/ /=)ƒ(°E((§[(2 zI$- n 7c% &nEs7&I-©\,,o,na062©S n{`fF, CD o-k`0. Ro rl kjE a}f 0227|® ](}Em(\)% 5 Ira §/|) 0 0E{, 2