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HomeMy WebLinkAbout0897A i WORKERS'COMPENSATION�ECIARATION 76A663 i0i8t ApPEiCATtON FQR ELECTRICAL PERMIT I hereby affirm �ho� I hove o reriiiicate of consent to self �-�' � insure.or a certifimte ot Workers'Compensation insurance, GOUNTY OF LOS ANGELES BUILDING AND SAFETY � or a cer�ified copy thereof�Sec.3800 tab�.JC.). Policy No���1Fa�mpan��l.1f��n� ��`P FOR AiPUUHT TO HI.L IN DDRE55 � � 1 � Certified copy is here6y fvrnished. New Residential Bldgs.8 Pools EACH NO. fEE � Os _ g LOCAUTY rn Cenified copy is filed wilh�he couMy building inspeo- 1 8 2-Pamily,$q.Fi. 1 lion depo�finent. 1 � Mu��i-family Sq.Ft. ROSS ST. �7n(�,� PP ���t G�.�`����� ResidenrwlSwimmingPoois FlRMNAME � Oare LdE}�_1—A licant (f (� Y CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ ��� /�,� ' COMPENSATION INSURANCE A�DRE55 ►`! �� First 20 � (Thls s�elion n�ad nol iro complN�d if th�work involv�d by To�al No. Additional CITY Tet. Iho p�rmit is fo�one hund��d dollors(;100)or losa.) PLAN E I certify�ho�in tha perfarmance of the work for which this A7ViICANT � permrt is issued,1 shall nor employ eny person in any manner so,r-�o bemme sobjact to the Workers'Compensation taws. �'9M��9 f�xtures First 2D _ ADORESS � Additiorro4 � Totol No. CITY Tel.No. D�te ApplicaM p�x�qpplionces Not Over t HV pERMIT 1 ' � �ICE TO AP�LICANT: if, after moking this Certificota of qVMIC4N7 � ..:mption, you sFould bemme subject to �he Workers' Ronge_Heater_D.W__ Compensa�ion provisions of ihe Lo6or Code,you must forth- Oven _Dryar _W.M.— A�DRESS with comply wi�h such provis�ons or fhis permil shaif be Top —FAU —W.H.— deemed revoked. Hood _Fan _Other_ CITY� , Tal.N � IICENSED CONTRACTORS DEf1ARA110N uCE�uSE OR .�`, ,n! t herehy pffi.m that�om licensed�nder provisions of Chapte�9 Disp. _Roam Air Cond _ REG.NUn�eER �i� �"! C�Ou•�.�G'7 commenci with Section 7000 of Division 3 of ihe&usiness DISTRICi NO- PROCE D BY ( R9 1 Power Apporatus 8 Large Appliances � ard Professions Code,and my license is in tutl force and effeci. 'f Size&Type HP,KW.KYA,w KVAR C3 License Number Up to 1 fnct. FINAC 2.�,�Z��'"F7lk.Class d.' JjhlZ,���� ,�� Over 1 io 101nc1. DATE ��G K VALIUATION � l �s:1 � co��.o��o�t/ t Over 10�0 50 Inci. FINAI � I am exempt under Sec, Over 50 to 100 Inc. BY d B.BP.C.for ihis reason Orer 100 Z s Services,Swbd.,MCC 8 Panelboards � Dote: p_ppp pmp.Under 60Q V SignaWre 201-1000 Amp.Under 6W V � Over 1p00 Amp.or Over 60p V `xemption for Reg.Maint.E1ecr. ' SINGLE FAMILY Temp.Power Pole&Appurtenencea �' j - , HOME OWNER-BUILDER DECLARATION giy��„ith pne&oncb CNcuil � � 1�ereby affirm Ihat I om exempr from�he Confroctor's ticense Additional Si n nch Circu�,. _ � Law for�he following reoson(Section 7031.5, Business ond ('���c� Professions Code): � �C �Q$9�7 A ❑ I,as owner of the property,wili da�he work and the Misc.Canduits&Conductors Other See Com lete Fee Schedule_ `���� � �2 structure is not intended or offered for sale (Sedion � P � � 7�44,Business and Professiom Codej. � � �3 a 5 Q CONSTRUCTION LENDING AGENCY � ° ' n 1 hereby offirm that ihere is o mnstruUion lending ogenty for Q�2�����U the performonce of�he work for which ihis permi�rs issued pERMIT FEE (Sub-Total) " (Sec.3047,Civ.C.)- PLAN CHECKING FEE Lender's Ncme PERMIT ISSUING FEE Lender's Address I certify tha�I have reod this application and stare that the TOTAL FEE a6ove i�forma�io�is correct.I agree to comply with oll Coun�y ordinonces and Slote laws regulating Electricol wiring,ond hereby authorize represe�lotives of rhis Co�nty to enfer�pon +he above-menrioned p�operry io� nspecnon urposes. 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