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HomeMy WebLinkAbout0897A (4) i WORKERS'COMPENSATION�ECIARATION 76A663 i0i8t ApPEiCATtON FQR ELECTRICAL PERMIT I hereby affirm �ho� I hove o re.iiiicate of consent to self �-�' � insure.or a certifimte ot Workers'Compensation insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY � o�a certified copy thereof�Sec.3800 tob�.}C.). Policy No���l�mpan��yf��n� ��`P FOR AiPUCAHT TO Hlt IN DDRE55 � � 1 � Certified copy is here6y furnished. New Residential Bldgs.8 Pools EACH NO. fEE � Os _ g LOCAUTY rn Cenified copy is filed wilh�he couMy building inspeo- 1 8 2-fomily,$q.Ft. � ron depo.rment. +� � Mu��i-family Sq.Ft. — RO55 5T. —ei�— PP {�I�LLf r.l.��1Y"��(l7h Residenrwl Swimming Poois FlRM NMnE � Oate A licani CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ ��� /�,� ' COMPENSATION INSURANCE A�DRE55 ►`! �� First 20 � (Thls s�elion nwd nol iro eomplN�d if th�work involv�d by To�al No. Additional CITY Tet. Iho p�rmii is fo�one hund��d dollors(;100)or losa.) PIAN E I certify�ho�in tha perfarmance of the work for which this A7ViICANT � perm�r is issued,1 sholl nor employ eny person in any manner so,r-�o bemme sobjact to the Workers'Compensation taws. li9Ming fixNres First 2D _ ADORESS � Additiorro4 � Totol No. CITY Tel.No. D�te ApplicaM p�x�qpp(ionces Not Over t HV pERMIT 1 ' � �ICE TO AP7LICANT: if, after moking this Certificote of qVPLIC4N7 � ..:mption, you should bemme subject to �he Workers' Ronge_Heater_D.W__ Compensaiion provisions of ihe Lo6or Code,you must forth- Oven _Dryar _W.M.— A6DRE55 with comply wi�h such provis�ons or fhis permil shoil be Top —FAU —W.H.— deemed revoked. Hood _Fan _pther_ CITY� , Tal.N � IICENSED COSJTRACTORS DECLARATION uGENSE OR .�`, /�� t herehy dffi.m that�om licensed�nder provisio�s of Chapte�9 Disp. _Roam Air Cond. _ REG.NUn�eER �i� �! C�Ou•t.�G'7 commenci with Section 7000 of Division 3 of the Business DISTRICE NO- PROCE D BY ( M3 1 Power Apporatus 8 Large Appliances � ord Professions Code,and my license is in tutl force and effeci. 'f Size&Type MP,KW,KYA,w KVAR C} License Number Up to 1 fnct. FINAC 2.�,�Z,��'"F7lk.Class d.' Jjh��.,�j�f� ,�;1���7 Over 1 io 101nc1. DATE ��G K VALIUATION � � �:� � co��.o��o�t/ Over 10�0 50 Inci. FINAI � I am exempt under Sec, Over 50 to 100 Inc. BY d B.BP.C.for ihis renson Orer 100 Z ; Services,Swbd.,MCC 8 Panelboards � Dote: p_ppp pmp.Under 600 V SignaWre 201-1000 Amp.Under 6W V � Over 1Dp0 Amp.or Over 60p V `xemption for Reg.Maint.E1ecr. y�' SINGLE FAMILY Temp.Power Pole&Appurtenencea �' / - , HOME OWNER-BUILDER DECLARATION giy��„ith pne&oncb CNtuil � � 1�ereby affirm Ihat I om exempr from�he Confroctor's ticense qdditional 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 � � 7044,Business and Professiom Codej. � � �3 a 5 Q CONSTRUCTION LENDING AGENCY � ° ' n 1 hereby offirm that ihere is o mnstruUion lending ogency for 0�2����U the performonce of�he work for which ihis permi�rs issued pERMIT FEE (Sub-Total) " (Sec.3097,Civ.C.)- PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify tho�I have reod this application and stare that the TOTAL FEE a6ove i�fwma�io�is correct.I agree to comply with all Coun�y ordinonces and Slote laws regolating Electricol wiring,ond hereby authorize represe��otives of rhis Co�nty to enfer�pon the above-menrioned p�operry io� nspecnon urposes. 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