HomeMy WebLinkAbout1752A " WORKERS'COMPENSATION DECLARATION 76A563 t0i61 qpp��CATfON FOR EL�CTRICAL PERMiT �
f hereby affirm thm 1 hove a certifimte of cansent to self CE-BOtG
• insure,or a certifiwre ot Workeri Compensatlo�I�surance, � � C�UNTY OF LOS ANGELES BUILDING ANO SAFETY
� a�a�tifjed(jy�hg�eo�5�3800,Lob.C �) ,N `
( 1 �„
I ❑ty No(� .�C'� om any FOR APPUCANT TO Flll 4N JOB �
Certified to is hereb furnished. � EACH NO. FEE ADOkESS tn
py y New Residential 81dgs.8.P yo�l' Q �pCq��TY
� ❑ 4 8 2-famil Ft�(Sd�— f ' s � �
� Certified topy is fited with the muniy 6vilding inaper Y'�' ,_ r�EAREST
tion deportmen�. Mu�ti-family Sq.Ft. CRO55 5T.
�-1`�l•� pplicant �������- ResidenliaV Swimming Poofs OWNER OR
. Dafe A �, FIRM NAM
CERTIfICASE Of EXEMPTION FROM WORKERS' Outlels:Rec_light_Sw._ N''41L
COMPENSATIOhI�NSURANCE nD�RE55
Firsf 2(1
` (TNI�totlion nNd no�la�compl�Nd H Ih�work inrolvad 6y Total No. Addilional CI Y Tel.No.
� fh�p�rmit is for ona hundrod dellan(=100)or lep.) p�qN C� t�{� �4+
� I certify ihat in Ihe performance of the work ior which Ihts APPLICANT
- parmit is issued,i shoit no�employ any person in any manner
so os to become aubject to fhe Workers'Compensotiort tows. li9Ming FixWres Firet 20 ADORESS
� Addilional
f� �`� A Tofal Na. CITY Tel.No.
f Date��`��� �pplicam � Fixed Applioncea Not Over 1 HP
4 "E TO APPLICANT: If, after making Ihis Certificate of PERM17 C
' E �ion, you :hould 6ewme subjed io the Workers' Ronge_Hepte�_.D.W.__._ AP�IK�NT
� ����pensat�on provisions of the Lahn[Code,you must.fwth• Ovan _Dvyer ._W.M.— AODRE55 � �.
with comply ith such provisions or this permif ahall be Top .—FAU —W.H.— r. „
� deemed revoked. Hood �fan _Other_ CITY 4 el.No. ���7
LICENSEO CONTRACTORS OECtARAT10N ���N��
t hereby affbm thai I am licensed under pravisions of Chapier 9 Disp. _Room Air Cond. — REG.NUMBER�� '��-� ��°�' '"�� F
. (commancing with Section 7000)of Oivision 3 of the Business D15TRICT NO. PROCESSED 2 �
ond Profess�ons Code,and my Gcense u in f�ik fdca and effeci. Power Appora�us 8 Lorge Applionces U �
n ,� Si:e&Type HP,KW,KVA,o.KVAR �
License Number � � Lic Ciass_.�S.�L� �P io�����, FINAF � �
Over 1 ro 10 IncL �A� ��l/�g VALIDATION �
Confroctor ����-1 Date `�`'Gg� Ove�10 to 50 Ind. . V
DBWAL c.t �i r�.i i; a
I am exempt under$ec. Over 50 to iD0 Inc N
B.&P.C.for this reosan Over 100 : .. t �[ Z
Services,Swbd.,MCC 8 Ponelboards � F ` ' �- ��'�`
�ote: p_2pp qmp.Under 600 Y o ' � ,< x I
Signature 201-7000 Amp.Under 600 V
❑ Over{000 Amp.or Over 60p V 1 ;. � . . .. �
Exemption far Reg.Muint.Elect. +
SINGLE FAMILY Temp.Power Pole&Appurienances i
HOME OWNER-BUIIDER DECLARATlON Sign weth One 9ranch Circuit .
1 k �affirm ihot 1 om exempt from the Contractor s license qdditionol Sign Bmnch Cirwits
La�. ,r 1he followinq reason(Section 7031.5,Business and
Professio�s Code�:
❑ I,as owne�of Ihe property,wi�l do fhe work and the Misc.Cond�its 8 Conductors
structure is not intended or offered for sole(Section Other(See Complete Fee Schedule)_ �
7044,Business arrd Professions Codej.
CONSFRUCTION LENDING AGENCY
1 hereby oHirm that thera is o const.oc�ion lending ogency for
the p¢rformance of the work for which this permit is iss�ed PERMIT FEE (Sub-Totol)
(Sec.3097,Ci�.C.�.
PtAN CHECKfNG fEE
Lender's Name PERMIT ISSUING FEE r�
lender's Address + �
I cerlify thal I have read Ihis application and state ihat the TOTAL FEE �
o6ove infa.moiion is correcf.I ag�ee ro comply with all County
ordinances and State lows reguloting Electrlcol w�ring,ond
he�eby oulhorize representatives of Ihis County to en�er upon
ihe pbo�e-mentio roperty for inspecnon purpases. SEE REVERSE FOR EXPLANATORY LANGUAGE
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