HomeMy WebLinkAbout1759A WORKERS'COMPENSATION DECLARATION 76A663 t0iei APPL1eqT�ON FOR EL�CTRICAL PERiViIT �
I hereby affirm tha� I have a cer�ificote of wnsen�to self CE-806G
ins�re,or a certiFicare ot Warkers'Compensotion Insurance, � UNTY QF COS ANGELES BUlLDING AND SAFETY
or a c'g��)hfied ca � er f Sec 800,Lab.C.) , � Lj
�J�������� fOR APPLIGNT TO FIL[IN � JOB 1
P❑ol�icy o. Company �
Cerlified Copy is hereby furnished. New Residential Bldgs. o,yls EACH NO. FEE ��E�, �
� 1 8 2-Famil S Pt. � s — S LOCAIITY
Certified copy is filed with 1he coanty bvilding inapeo Y• 4�
�ion depariment. Multi-family Sq.Ft. ROSS 5T.
� Residentin{Swimming PooVs OWNER OR
Date � AppficaM � �Q 9���^ FIRM NAME
CERTIFtCAiE OF fXEMPTION FROM WORKERS' OuNe1s:Rec_Light_Sw..�_ ���
COMPENSATION INSURANCE AO�RESS�
First 20
(This s�Nlow++wd�b�compla4ed H ths work involv�d by To�o�Na. .4dd��ional C�TY Tel.No.
1he pormlf is for owo kuadr�d delhn(t108)ar f�t�.) PIAN CHECK ��
1 certify that in+he perfamance of the work fw which�his pVPtICANT
permit is issued,i sholl not employ any persan in ony manne�
so ns to 6ecame eub�ect to the Wwken'Compenw�ion laws. Li9h�ing Fiafures first 20 AODRESS
�(} 4, „ Total No. �d�t`O`!°� CITY Tel.No.
Date (��Japplirnro `•X�L�Y Fixed Appliances Not Over 1 HP pERAVT _
f�"'CE TO APPLICANT: If, after moking�his Cerfificate of qpp��GqNT p �
�y �tian, you should become wbjecl to the Wakers Ranqe.�HealCr�Q.W.._....
--.pensotion provisions of iFe La6or Code,yo�must forth- Oven _Dryer _W.M._ ADDRE
wirh tomply wirh wch provisions or rhia permlt shatt be Top _PAU —W.H.— �
deemrd revokad. Hood _Fan �Orher_ CITY � � � G�,yp1y 1.No.('p af�
UCENSED C6NTRACTORS DECLARA�ION UGFNSE OR /� �
Disp. —Room Air Cond. — REG.NUMBER ���- . C�au�l.`���}
!hereby affwm ihar I om licensed urrcler provisions oi Chopter 9 �-
(commencing with Secfion 7000�of Division 3 of tha B�siness DISTRICT NO. PROCE BY 4 �
ond Professions Code,and m "ense i:in full force and effect. Power ApporaWs&Lorge Appliances Q�
,�a.Lk���2.�a c t� Size&Type HP,KW,KVA,or KVAR V
License Num6er�__��c.Class Up to 1 Ind. pATE� G � i
(� : _ n ,2`1n,m r)- Over 1 fo 101nc1. �l��O�o VALIDATION f' �
Controcror h SL�V pa�e_ ntQ W s
Over IQ to 50 Ind. fINAt
❑ I am exempl�nder Sec Over 50 to 100 Inc BY ��y����� /� a �g
O�er 100 /�"( � Z i
B.BP.C.far this reaaon �
Dote: `�����es,Swbd.,MCC 8 Panel6oards � 1
, 0-2(p Amp.Under 600 V _ j 'i�� .� I
Signoture 201-7000 Amp.Under 600 V �
❑ • Ove.1000 Amp.or Over 600 V ,. - � , � 1
Exemption for Reg.Mainl.Elecs. �r �
SIMGLE FAM{LY Temp.Power Pole 8 Appurtenantes � " ' ' • - I
HOAhE OWNER-BUILDER DECIARATION S�y�„V�th O�e&onch Circuit . - - � - _ f
I� y affirm that V am exempt from the Controctor'tLicense Rddifionaf Sign Bronch Grcuits � � � ���
LO.. ,r the foilowing reason(Sectian 7031.5, Business and �
Professions CodaJ: i .' i �i—-'"� �
❑ I,as owne�of the p�operly,will do ihe work ond�he Misc.Condui�s 8 Conductws
strucwre is not intended or ot4ered fo�sale(Section Olhar($ee Complele fee ScheduleJ_ �
7044,Business and Professions Code�.
. CONSTRUCTION LENDWG AGENCY -
I hereby nffirm that there ie a construNion lending agency for
Ihe performance of the work{or which this permi�is fssued pERMIT fEE (Sub-Total)
(Sec.3097,Civ.C.).
PLAN CHECIGING FEE
Lender's Nome
PERMIT ISSUING FEE j
lendeis Address �
I certlly fhat i have read ehis applimtion and srate ihat the TOTAL fEE t� e
a6ove infamaiion is cwrect.I ag�ee to comply with all Counry
ordinances and State Iawz regulating Elecrrical wiring, and
hereby au�horiza representotives of this County to enter upon
the above-mentione preperty for inspeciion p�iposes. SEE REVERSE FOR EXPtANATORY LANGUAGE
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