HomeMy WebLinkAbout1759A (225) WORKERS'COMPENSATION DECLARATION 76A663 10�ei APPL1eqT�4iV FOR EL�CTRICAL PERMIT �
I hereby affirm thal I have a cer�ificote of wnseN to self CE-806G
ins�re,or a certiFicare ot Warkers'Gompensotion Insurance, � UNTY(SF COS ANGELES BUlLDING AND SAFETY
or a c �hfied co � er f Sec 800,Lab.C) � ,1,�
�t�t�"�`�b�o�
P❑ol�icy o. Compony fOR APPLIGNt TO FIL[IN � ��E�� � 1 I
Cer�ified�opy is hereby furnished. New Residential Bldgs. o,yls EACH NO. FEE
� l 8 2-Famil S Pt. � s — S LOCALITY
Certified copy is filed wilh�he mvnty bvildi�g inapeo K 4�
�ion depariment. Multi-family Sq.Ft. ROS9 5T.
p f1 � Residentio{Swimming PooVs OWNER OR
Date � AppficaM Y �.V 9 G�i n FIRM NAME
CERTIFtCATE OF fXEMPTION FROM WORKERS' OuNe1s:Rec_Light_Sw..�_ ���
COMPENSATION INSURANCE AO�RESS�
First 20
(This s�dlow nwd nof b�comploted H the wotk inrolv�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 �j�
1 certify that in�he perfamance of the work fw which�his aPPLICANT
permit is issued,i sholl not employ any persan in ony manne�
so ns to 6ecame aub�eU to the Worken'Compenso�ion iaws. U9h�ing Fia�ures first 20 ADQRE55
'-� 1 �(} `, „ Total No. �d�t`O`!°� CITY Tel.No.
Date .�-�PC' '�pplicuM `•X�L�Y Fixed Appliances Not Over 1 HP pERAVT _
fy"'CE TO APPLICANT: If, after moking this Certificate of qpp��GqNT p
�y �tion, yo� should become sub�ect to the Workers Ranye.�HealCr�Q.W....�..._
--.pensotion provisions of iFe La6or Code,yo�must forth- Oven _Dryer _W.M..— ADDRE
wirb comply wirh soch provisions or �hia perm�t shaR be Top _PAU —W.H.— � . �
deemrd revokad. Hood _Fan �Orher_ CITY � � G�,yp1y 1.No.('p af�
LICENSED C6NTRACTORS DECLARATION UCFNSE OR n �
Disp. —Room Air Cond. — REG.NUMBER ��- . ��Ou�l.`���}
!hereby affwm ihar I om licensed urrcler provisiorn oi Chopter 9 �-
(commencing with Secfion 7000�of Division 3 of�ha Business DISTRICT td0. PROCE BY 4 �
ond R'ofessions Code,and m "cense i:in full force ond effect. Power Appomtos&Lorge Appliances Q�
U
��.Lh� �l,�d � Size&Type HP,KW,KVA,or KVAR � 6
Lfcense Num6er���c.Class Up to 1 Ind. FINAL �� p
Over 1 to 101nc1. DATE �l���J VALIDATION � �y
Controcror � Date ,2`�'{'�•S j� � �
❑ Over I Q to 50 Inci. f�Nq� W
I am exempt�nder Sec Over 50 to 100 Inc BY a tg
O�er 100 Z 7
B.BP.C.fa�this reason �
Dote: °�����es,Swbd.,MCC 8 Panel6oards � 9
, 0-2(q Amp.U�er 600 Y - I i�� r �
Signoture 201-7000 Amp.Under 600 V � ^� �
❑ • Ove*1000 Amp.or Over 600 V ,. - � • � ' �
Exemption for Reg.Mainl.Elecs. �� �
SIDtGIE fAM{LY Temp.Power Pole 8 Appurtenantes � ' ' • " I
HOAhE OWNER-BUILDER DECIARATION g�y�„V�th O�e&onch Circuit . - - - � - _ j
1� y aHirm thol i am enempi from the Convoctar'tLicanse pdditlonaf Sign Bronch Circuits � � � ���
Lcl.. ,r the foilowing reason(Sectian 7031.5, Business and �
Protessions CodeJ: i .' i i— �"� �
❑ I,as owner of the p+operly,will do ihe work ond�he Misc.Condui�s 8 Conductors
strucwre is not intended or of4ered fo�sale(Section Oihar(See Complele Fee Schedule)_ �
7044,Business and Professions Code�.
. CONSTRUCTION LENDWG AGENCY �
I hereby nffirm that there is a construNion lending agency for
Ihe performance of the work{or which ihis permi�is fssued pERMIT fEE (Sub-Total)
(Sec.3097.Civ.C.�.
PLAN CHECIGING fEE
Lender's Nome
PERMIT ISSUING FEE '
lender's Address
I cerGly fhat i have read ehis applimtion and srate ihat the TOTAL fEE t�
a6ove infamaiion is cwrect.I ag�ee to comply with all Counry
ordinances and State Iawz regulating Elecrrical wiring, ond
hereby au�horiza representotives of this County to enter upon
ihe above-memione preperty ior inspecuon pmposes. SEE REVERSE FOR EXPtANATORY I.ANGUAGE
� l�l���
Signa�ure�irree Date
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