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HomeMy WebLinkAbout8008A (20)WORKERS' 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 Na.o'), 9C) CompanylA 12 rt 1_1a (14 . Certified copy is hereby furnished. Certified copy is filed with the county building inspec• tion department. /^ Date A -I_ 36 Applicanr,,pz4 i'\i 1•pP'TP L(" 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 tCE TO APPLICANT: If, offer making ibis 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 I"Z;s tic. Class C 10 Contractok4VPv ll{I LfM- Date A Z an u I am erempl 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 r EACH NO. FEE ADDRESS New Residential Bldgs. & 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 T. OFIRMNWNERAMEOR (( Outlets: Rec_Light_Sw._MAIL First 20 ADDRESS Total No. Additional CITY C o iG ffip,Tel. 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 PLAN CHECKING FEE PERMIT ISSUING FEE TOTAL FEE ADDRESS CITY Tel. No. PERMITAPPIICAN ( ADDRESS CITYPI LICENSEREG. NUMBER DISTRICT NO. C) PROCESSED BY a, FINALDATE S ,y VALIDATION FINALBY / Sub•Totol) 1 1 1 SEE REVERSE FOR EXPLANATORY LANGUAGE 0. sorsa Ne se •*2 1 2646 e^126 41.63 05.06-87 0 90 t k k cn 9 2//|\$/ §2§e[r[mtfR; 2e\=ar CL. m\(B0-}®;i,; eE§2[:}{, 22§\ k -aA° - 0 x keso§§2E—e eEz%%eo®o zzz=@k em,eE2|E/ /(Iƒ(E((§[(2 II&- 7&I \,,Co,n E°a 2©S nc{`f t C3 0. zzz$\kjE a}f 0227|® ](}Em'(\)% 5 »JEER\r\E*/)\ CL a- 0 §ƒ(§/|)/k)R I aa %a=moo Rk ;TE:e}7(§-.r660, 9 m7,. - 2 k k 0n 2 z 0 G d m Clz 2//|\$/ §2§e[r[mtfR; 2e\=ar CL. m\(B0-}®;i,; eE§2[:}{, 22§\ k -aA° - 0 x keso§§2E—e eEz%%eo®o zzz=@k em,eE2|E/ /(Iƒ(E((§[(2 II&- 7&I \,,Co,n E°a 2©S nc{`f t C3 0. zzz$\kjE a}f 0227|® ](}Em'(\)% 5 »JEER\r\E*/)\ CL a- 0 §ƒ(§/|)/k)R I aa %a=moo Rk ;TE:e}7(§-.r660, 9 m7,. - 2