HomeMy WebLinkAbout1706A (225) WORKERS'CONPENSATiONDECLARATION 76A663 ppp�ICATION FOR ELECTRI�AL PERMIT � {�
'CE�SO6G 1290) � �
1 hereby atfirm that I have a teniticate ot consent to ulf '. COUNTY OF LOS ANGELES BUILDING AND SAFETY �1
insure,ot e tertit7cate of Workers•Compensatlon Insurance,or ' � �
a certified copy thereo((Sec.380 Lab.C.
��' ���' FOR APPLICANT TO FILL IN JOB �1�1 ��/
Policy���L.[[�-5L(:ompany EACH NO. FEE A�DRESS osV O Lif/
New Resfdential Bldgs.&Poois ''J
� CerlifieJ copy is hereby furnished. �� � 1&2-Family,Sq.FL. $ — s LOCALITY �ti
{.,q�Certified copy is fied with the counly buildin Mutti•family Sq.Ft. CROSS ST '
g inspectian Residential Swimming Pools
(" department. OWNEROR
� /�o/'y FIRM NAM
Date Applica��'1�f.L����� Outle[s:Rec.��ght�Sw,� MAIL
� First20 ADDRESS
CERTIFICATE OP EXEMPTION FROM WORKERS' Total No.�— Additional CITV T �� }
. COMPENSATION INSURANCE - � � PLAN CHECK . a
(This section need no[-be completed if the work invoived APPLICANT �
Lighting Fixtures First 20 qDDRESS �
6y the peimit is for one hundred dollars (SI00)or Iess.) Additionel �
�Total No.� �
I certify that in the.performance of the work for which this Fixed Appliances Not Over 1 HP CITv� � 7el No.
� permit is issued.1 shall not emplvy any person in any manner PERMIT W
sq as to become subject to the Workets'Compenselion Laws. Range��Heater D.W.^ APPLICANT � p.
Oven _,,,_Dryer_W.M._ ADDRESS �
Z
Dete - Applicant Top _FAU _W.H,_, CITY T N
Hood_Fan _Other— �
NOTICE TO APPLICANT:If,after making this CerHficate of Disp. _Room Air Cond._ LICENSE OR �f _ /1_
Exemption, you shouid hecome subject to the Workers' " REG.NUMBER / Class Ci ,
Compensation provisions of the Labor Code,you musf forth- Power Apparatus&Lar9e Appliances DISTRICT NO. PROCESSED BY
with comply with�such provisions or this permi� shalf be Size&Type HP,KW,KVA,or KVA � -
deemed revoked. - . - .
. Up to 1 InCI. FINAL
Over7tot01ncl. oArE ��?�j^Fj VALIDATION
LICFNSED CONTRACTORS DECLARATfON Over 10 to 50 Inel, � •
1 herehy atfirm that I am Iicensed under provisions of Chapter Over 50 to 100 Int. gY AL , �
9(commencing with Section 7000)of Division 3 of the Rusi- Over 100
ness and Professions Code,end my license is in full force and .
effect. � Services � E
Ucense Nu e Lia Ctass �'�� 0-200 Amp.Under 600 V ' �1 7 0 6 A
201•1000 Amp.Under 600 V .
Contra e Wer 1000 Amp.or Over 60D V � . ��� �' �/�
I' y •(�'4 v li
HO�fG OW R-BUIL R DECLARATION Temp.Power Pole&Appurtenances � s e ,.�,'�,F Q.'—. �
1 hereby aff'vm that I am exempt lrom the Contractor's Sign with One Branch Circait '. � �'[�'2 j=�j'�
License Law tor the foliowing reason(Section 7031.5,Busi• Additional Sign Branch Circuits _ �
ness and Professions Code): � �
Misc.Conduits&Conductors � � '
� I,as oxmer of Ihe property,will do the work and the Other(See Complete Fee Schedule)— �
structure is not intended or offered for sale (Secdon
7044,Ausiness and Professions Code).
CONSTRlICT10N LENDINC ACENCY - -
I hereby affirm ihat there is a constmction Iending agency " -
!or the performance of the work for which this permit is , ; pERMIT FEE (Su6-Totall
issued(Sec.3097,Civ.C.). .
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Fee) �
Lender's Address PERMIT ISSUING FEE � O
1 ttrtify that I have read this application and state that the TOTAL FEE � ```��� .
above informalion is rorrect.1 agree to comply with all Connry �
ordinances and State I8K9 rogulating Eloctdca� wiring, and . ,
hereby authori¢e represrntatives of this County to enter upon .)
the above- ntioned pro erty for inspection purposes. SEE'RGVERSE FOR EXPLANATORY LANGUAGE -
I �gnature of Permi Uale . � �
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