HomeMy WebLinkAbout1419A (433) WORKERS'COMPENSATION DECLARATION 76n663 i0/81 APPlICATION FOR ELECTRICAL PER1UlIT � I
I hereby affiim that I have a certificate of consent to self CE-806G
insure,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
ar o certified copy�hereof(Sec 3800,1a6.C.)
P�o�llcy No. Compony FOR APPLICANT TO Fill IN JOB .1 ' 1 ' n
Ceriified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ADDRESS ��(J"'jT �`��or,,,� �,v��C.k
� 1 8 2-Famil q. f — E LOCALITY D •
Cerfified copy is filed wifh the county building inspeo- y,5 FI. t 0.v�np 6 c.,r'
lion depa�tmenc Multi-family$q.R. — NEARE57
Residential Swimming Paols Ce05557.
Date Applicnnt OWNER OR _`f
FIRM NAME wT �Gl.a.. O r'�'
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets�Rec_Ligh�_Sw._ '��� �
COMPENSATION INSURANCE a�oae55 ,2'�GT4 f.,,,��tlw 'E��cy�G Q
(This seclion nwd nof 6�complN�d B!ho work Invol�ad by First 2b
the permlt is for ona hu�drod do�lan(SI00)ur irss.) Total No. Add+iional CITY �0.„y\p �Tel.No.C't/4�Stil i E 2Z
!certify thet in the performance of the work for which ihis PLAN CHECK
permit is issued,I shall not employ any person in any manner APaLICAN7
so as to bemme su6jed m the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS �
�� �� �� Total No. Addilional
Daie�pplicanl CITY 7e1.No.
Fixed Appliances Not Over 1 HP pERM�T
NOTICE TO APPLICANT: If, after making fhls Certif' of APPLICANT �(1 q
Eremptian, you shoutd becoma subject fo the rk rs' Range—Heater_D.W. _
Compensation provisiom of the Lobor Code,you must Ih- Oven _pryer _W.M.— ADpRE55 ' � , 0.t J,L
with comply with such proaisions or this permit sholl be 1op —FAU _W.H.,
deemed revoked. CITY ��C l Tel.No. CY(��.Zg�
LICENSED CONTRACTORS DECLARATION Hood —Fan _Orher_
Disp. —Room Air Cond. — �iCENSE OR
I hereby affirm�hat I am lirensed under provisions of Chop�er 9 REG.NUMBER 4�s (Q' i � C�oss. C��J �
(commencing wilh Sectlon 700D�of Division 3 of the 8usfness power Ap¢oralus 8 Large Appliances DISTRICT NO. " PROCESSED BY
, and Professions Code,and my license is in full force ortd effect. /� 6 �
Size&Type HP,KW,KVA,or KVAR �
license Number 4 r��� Lic.Class G 20 Up to 1 Ind. FiNAL V �
(',,�o Over I to 10 Mcf. DATE ` � �
Confractor �`�`�� y'� Doie� t F s Over 10 to 50 Incf. �.. `—��� VAIIDATION ' �
❑ I om exem i under Sec. FINAL� W �
p Over 50 to 100 Inc 8Y � ! �
Over 100 � a
B.SP.C.for�hi:reason z
Services,Swbd..MCC$Ponel6oards / / �
�Of°� 0-200 Amp.Under 600 V v� � 1{
Signature - 201-1000 Amp.Under 600 V �v��.'^.�.�J„� �a); �
❑ Over 1000 Amp.or Over 60p V {� (' �1 4 1.9 A
Exemplian for Reg.Moint.EIecL f n*�"a:; r� s
��`��-�G7,(' �j• • • • •� �
SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION $ign wilh One Branch Cirwil �C' ��'�6�"�' I • �z��O
I hereby affirm ihat I om exempt from the Conhactor's license qddi�ianal Sign&anch Circuits - �,. �
Law for fhe-fo�lowing reason(Sec�ion 7031.5, Business and �-' � � m��r�,1` �
Professions Code):
❑ I,as owner of the property,wi�l do the work and the Misc.Conduits 8 Condoctors �' � ���� �
slrutlure is not intended or oHered for sale (Sedion Other(See Complefe Fee Schedule)_ �
1044,6usiness and Professions Code).
CONSTRUCTION LEWDiNG AGENCY
1 hereby offirm thpl there is a construclion lending ogency fo�
the performante of ihe work for which ihis permit is issueH pERMIT�EE (Svb-Total) .
(Sec 30Y/.Civ.C.).
PF.AN CHECKiNG FEE
lender's Name �
PERMIi I55l11N6 fEf , �O
tender's Address � -� -- � � �
I certify that i hore read�his appl�corton ond stme ihot rhe TOTAL FEE ��
above information is correct.I agree to compfy wiih all Counry
ordinances and State laws regulaling Eletlrfcal wiring, and
hereby authorize represenro�ives of�his Coun�y�o enter upbn
the o6ove•mentioned pr erty}or inspection purpases.
SEE REVERSE�OR EXPLANATORY LANGUAGE
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