HomeMy WebLinkAbout1774A WORKERS'COMPENSATION DECIARATION 0-�76n663 IOiBI o�J d 3 S ��o-���y�
I hereby o�{;,m Ihal I hove o certificofe of consenf to 5e�f �E-� APPLICATION FOR ELECTRICAL PERMIT �
insure,or a certifico�e of Workeri Compensa�ion Insurance, ^ COUNTY OF LOS ANGELES BUIIDING AND SAFETV
ar a cer�ified c f Sec.3800,Lob.C.) ����I�
❑ Y :��c:+������� P Y M"r�oe A '�
Polic No. Cam an s9'�/�Y.[f/V� FOR APPLICANT TO Flll IN JOB n '�
Ceni(ied copy is hereby furniihed. EACH NO. FEE AODRESS �`�Q 3 �/�4�yJ G%�/v /;�A� ��!
` New Residential Bldgs.&Pools
� 'Cer�ified copy is filed wilh Ihe county o Iding inspeo 1 8 2-Fomily,Sq.Ff. E — S IOCALITY L.t�AL/j/L'%
tion deportmen� �'� Mul�i-family Sq.F�. tROS555T. ��G/I��YI�r/
/ —1 �
Residential Swimming Pools
Dale Applicanl 'K �� OwNER OR � /
FIRMNAME -I. . �O ( Il �t�S , �!✓C / C[/
CERTIFICATE OF ExEMPT10N.FROM WORKERS' ,y,q�� �
COMPENSATION INSURANCE Outlels:Rec_Light_Sw._ ADDRE55�S�O Q✓,O� '�'y/7
(Thl���clfo�n��d nof bo complsl�d if Th�work involr�d 6y Fin�20
ih�p�rmit(�fer ons hundr�d della�o(S1D0)or ir�s.)
To1al No. Additional qTY/�/Ly/f/GPQ� rQ Tel.N6f'�lf�/�
'' I cnrtlfy thot tn�he performance of the work for which this PtnN CHECK
�� ermi�is issued,I shall nor em lo an erson in an APa�GANT
P p y y p y monner
.so os to bemme subject to the Wo�kers'Compensation Laws. ��gMing Fiatores Fir51 20 ApDRESS
� Total No. Addilionol
CITY Tel.No.
�Date epplicant Fixed Applionces No�Over I HP
'NOTICE TO APPLICANT: If, aHer moking this Cer�iiimte of a�Rwii G�
E�emption, you should become sobject to the Workers' Ra�9e_Healer_D.W._ APPLICANT� 'l�✓��ti
Compensaiion provisions of the Lobor Code,you must(or�h- Oven _Dryer _W.M._ ADDRE55 s�� � S R 3 o vE
.wiih comply wi�h such provisions or this permit shall be Top _FAU —W.H.—
deemed revoked. Hood _Fan _Other_ CIN Tel.No.
. . . IICEN5E0 CONTRACTORS DECtARATION �- uCeNSE Oa
I hereby affirm ihat I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. _ REG.NUMBER Class.
(tommencing wilh Seclion 7000)of Division 3 of�he Business DISTRICT NO. P 5 ED BY
and Professions Code,and my license is in full force and effect. Power Apparolus 8 Loige Appiiontez � Q;
. License Number( d Gf � Size 8 Type HP,KW,KVA,or KVAR� C1��,pjy� . V
�� 5 y Lia Closs�_ Up ro 1 Incl. FINAL
DATE f� �
�t�� J7 Over 1�o IO lnd. !p VALIDATION
O
Contracro� Dote ���-G�� Over 10 to 50 Ind. � U
� FINAL W
1 om exempt under Sec. Over 50 to 100 Inc. BY � p,;
8.8P.C.for this reason Over 100 z
• �� ��e: Services,Swbd.,MCC 8 Panelboa�ds —
0-200 Amp.Under 600 V r-� /!.4,4
Signarure Z01-1000 Amp.Under 600 V .
' Over 1000 Amp.or Over 600 V �� � ° � � �2
� Ezempt�on for Reg.Mo�nl,Elect.
� � •75.50
SINGLE FAMIIY Temp.Power Pole 8 Appurlenances s
� HOME OWNER-BUILDER DECLARATION �Sign with One Branch Circuif • ^ °C:i.7��
here6y of(irm thot I am exemp�{rom 1he Contrador's li[ense Addi�ional$ign Bronch Circviis
aw for the following reoson(SeUion 7031.5,Business and I Z�C—;�5
4olessions Code):
� I,as owner of the propeny,will do the work and�he M:SC•Condui�s 8 Conduc�ors '
struclure is not intended or aifered for sole(Sec�ion Other(See Complete Fee Schedule)— , � '
7044,B�Siness and Prolessions Code).
CONSTRUCTION LENDING AGENCY �
here6y afFirm�hot�here is a consrruc�ion lending agency for
ie performance of the work for which fhis permi�is issued PERMIT FEE (Su6•Torol) S �-
�ec.3097,Civ.C.).
PLAN CHECKING FEE
.rnder's Name �
PERMIT i55UING FEE �O
•nder i Address
:ertify that I have reod�his applicotion and siaie�hot�he TOTAL FEE . p�5�3 C�
+ove informofion is mrrect.I agree lo mmply wilh oll Counry
dinontes and 51a1e lows reguluiing Electrical wiring,ond
reb�au�horize representatives of ihis Caunty to enter upon
'qbo�e•m_��d properiy for inspeUion parposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE
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