HomeMy WebLinkAbout0676A (4) WORKEfiS'COMPENSATION�ECLARATION 76A663 10/81 APpLICATION FOR E�LECTRICAL PERMIT {�
� I hereby alfirm Ihat I have a cedificata of consent to self Insure, CE•e06G ��
�� or a tertificate of 1Vorkers'Compensation Insurance,or a certitied � COUNTY OF LOS ANGELES BUILDING AND SAFETY
� copy thereol l�c.3000.Lab.C.)
Por�No. SMP1376'�mp��T M-TnG,ran�P FORAPVLICANTTOFILLIN JOB �v/n �.^�/t'�T D
� Certified copy is hereb fumished. � , EACH NO. FEE AOD�iESS r�_.� i � r.�•. �
Y .. New Residential B�dgs.8 Pools
� �. � 7 8 2-Fami Ft. S — $ LOCALITY
Certified copy is filed with the cwn buildi inspection y��
NEAHEST
departmcnt. - Multi-lamily Sp.FL -
� cRoss sr.Lemon
� Date��Applican Residential Swimming Pools ' � - OwNER OR
. . FIRMNAMEC�min$ Electric
, CERTIFICCOMPENSA ON WSURAO CE�pKERS' p�tlets:Rec—L'ght—Sw.— _ A➢DRESS74-133 El Paseo $'t.Q.�.Q
� (This see[bn need not he completed M the work Imolved by the First 20 ,
permit is for one hundred dollars(5100)w lesa) . Total No. Additional - CRY Tel.No 4
1 certify lhat in lhe perfo�mance oF the vrork for which this permit PLAN CHECK •
is issued,I shall not employ a�person in any manner so as to � ' �PauCnra7 Same
I � become subjec[to ihe lVorkers'Compensati aws. � L'ghting Fixtures � First 20�--� � ADDRESS �
� Additional
i ' A� � Total No. CITY � Tel.No.
Dat Appiicant Rzed Appliznces Not Over 1 HP �
NOTICE TO�APPLICANT: If, c making this Gertificate ot PERMiT
Exemption,youshouldbecome ubjetltotheWorkers'Compensation Range_Heater_D.W. _ naRiGtM CUIMilI1S Electric
� .provisions of the L26or Code,yrou must lorthwith c«nPly wi�h such Own_Oryer_W.M._ ADDRESS 74�.33 EZ Paseo, $t2. 10
. provisions or ihis permit shall be deemed rewked. Top —FAU _W.H._ . .- CRY Pd11R D2SErt � Tel.No619 S E H 9O 4
LICENSED CONTRACTORS DECLARATION Hood—Fan _Other_
� I hereby affirm ihat I am licensed under provisions of Chapter 9 ucENse Oli _
Disp. —Room Air Cond. _ plass.
(commencing with Section 7000)of Drvision 3 of the Business and REG.NUMBER'
R'OIfSSlq13 COdO,2fld rt1y IiCCfISC i5 ifl(UII IO�CZ dnC 2fIBC}. pSTRICT NO. � PFOCESSE Y
Power Apparatus 8 Large Appliances
Size d Type HP,KW,KVA,or KUAR �
Ucense Number 4 4 73 S 4 Lia Class['-^�Q Up to i Intl. � �� - FINAL � �� �� �
Over 1 to 701nc1. �TE VALIDATION �
Contractor Cu7tIIl11IIS Elec. Dete O
❑ Over 10 to 50 Incl. FINAL �
I am exemp[under Sec. Over 50 to 100 Inc. gy /^
B.BP.C.for ihis reason Over 100 ��vv d
-- Services,Swbd.,MCC d Panciboards - S-�- �� 'n O�7•6 A� Z
� � �e' 0-200 Amp.Under 600 V �'^
Signature 201-1000 Amp.Untler 600 V � � � (�• • • • •z
� � - Over 1000 Amp.or Over 600 V �� l J ..
Exempti n 10i Reg.Maint EleCt ' • �2 ra Jr O �
� � � SINGIE FAMILV �- � ' Temp.Power Pole&Appurtenances
HO!"E 01NNER-BUILDER DECLARATION � - � � ���5 O�
I hereby alfirm Ihat I am exempt from lhe Contractor's License Law Sign with One Branch CircuR
foi lhe(oliowirg reason(Seciion i 031.5,6usiness and Professions p��'�"OQ'-�G�°e�"�'h C��'���9 � - � �� �-- --- . U 7..1 G�u�..
Code):
� ��� Misa Conduits 8 Conductors � � -_ . . _. ._
I,as owner of Ihe proDerty,wili do ihe work and lhe structure Other(See Complete Fee Scheduie
is not inteMed or ctfered for safe(Section 7044,Business 1— , '
and Professions Code). " - � � � -- �' �
CONSTRUCTION LENDING AGENCY . .
1 hereby atfirm that there is a construction lendirg agency for the
perPormance of the work foi which this permit is issued(Sec.3097,. pERMR FEE - . - � (Sub-Totap / —' - ._ . . .
Civ.G1.
� PLAN CHECKING FEE .. . . . . _ �
Lender's Name �
PERMIT ISSUING FEE
Lender's Address �
I certify that I have read this appl'�eation and state th2[the above TOTAL FEE
info�mation is correct.I agree to comp�y with a�l Couniy ordinances � - - �� � �
and Stale laws regulating Electrical wiring,and hereby aulhodze '
representatives of this County to enter upon the ahove-mentioned � - -" � - � - - - - ---
prope y for' ect" poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
.!� g�s f�7 _
ign r f Permd ee Date � �
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