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HomeMy WebLinkAbout1428A (8) � WORKERS'COMPENSATIONDECLARATION 76n663 APPLICATION FOR ELECTRI�AL PERMIT � CE�806G(2-80) � 1 hereby afftrm that I have a certificate ot consent to setf COUNTY OF LOS ANGELES BUIIDING AND SAFETY insure,or a tertificate nt Workers'Compensation Insurance,or a certiPed copy ereo��Sec.3800,Lab. ) 7L1)��CYY3S/ FOH APPLICANT TO FILL IN ,lpg y Poticy�o. Company i EACH fd0. FEE ADORESS �� �ZJ � y� 7� '� � New Residential Bldgs.&Pools — � � CeRified copy is hereby furnished. 1&2-Family,Sq.Ft. 5 — E LOCALITY Multi-famiiy Sq.Ft. � �ertified copy p filed with the c ty building inspection CROSS ST � department. _ Residential Swimming Pools � OWNER ON 17 Date Applicent F_ FIRM NAME ��, � C U Outlets:Rec._Light_Sw.� MAIL f � � �`� • Firgt 20 ADDRESS �'a CFRT[FICATE OF EXEMPTION FROM WORKERS' Total No. AdAitional Ct7Y Te1 No. COMPENSATION[NSURANCE � � � PLAN CHEC - a (This section need not be completed if the woxk involved Li hting Fixtures First 20 APPLICAN7 V by the permit is for one hundred dollars (S10D)or IessJ 9 qdditionel AODReSS a Total No. ciTv rel No. � 1 certify[hat in the performance of the work for which this F�xed Appliances Not Dver 1 HP ' permit is issued,I sha�l not employ eny person in any manner PERMIT W € so as to Aecome subject to the Workers'Compensation Laws. Range_Heater_D.W. APPLICANT � y N f Oven _Dryer_W.M._ ADDRE55�� a , S � � Z . nate Appficant - ?op _PAU ,W.H.._ � - Hood_Fan _Other_ � CITv -� ��� �al No. ��C�._3s � NOTICE TO APYLICANT:If,after making this Certificate of LICENSE OR '1G / --�7� Di�. ._Room Air Cond� REG.NUMHEIb�J� 3 D Class �: T � Exemptioa, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth• Power A g pp j pparatu9&lar e A liances OISTRICT NO. PROCESSED BY � � with comply with such provisions or [Mis permi[ shali be Size&Type HP,KW,KVA,ar KVAR � deemed revoked. Up to 1 Incl. � FINAL �.._ Over 7[0 10 Intl, DATE / [j LiCENSEDCONTRACTORSDECLARATION /� d � VALIDATION Over 70 to 50 Incl. I hereby affirm lhat I am ticensed under provtsions of Chapter Over 50 to 700 inc. �INAL � 9 (commencing with Section 7000)of Division 3 of the Busi- BY � Over to0 ness and ProPessions Code,end my license is in full force and � effect. - Services �3 G S� 0-200 Amp.Under 600 V ' License Nu Lic.Class 201-1000 Amp.Uoder S00 V � Contractor C Date ��'�' Over 1000 Amp.or Over 600 V ' � HOME OWNER-BUILDER DECLARATION Temp.Power Pote&Appurtenances � � 1 hereby affirm lhat I am exempt from the Contrador's Sign with One Branch Circuit License Law for the following reeson (Section 7031.5, 8usi- Additiongi Sign Branch Circuits y ness and Rotessions Code): �� ,\� � Misc.Conduits&Conductoro � � 1, as oxmer oi the proper[y,will do the work and the Other(See Complete Fee Schedulel-- stmcture is not intended or offered for sele (Sec[ion � 7044,Business and Professions Code). � CONSTRUCTION LENpING ACF;NCY \ � I herehy affirm that there is a construction lending agency n , fur the pertormance e ork for h" h this permit is ��/ � issued(Sec.3097,Civ.CJ. PERMIT FEE (Su6-Tata�) S - Lender's Name L PLAN CHECKING FEE (One-Fourth Permit Fee) _`/ � ,�� �l 2,�F I Lender's qddress ���'1 `` G H`� pERM1T ISSUING FEE ` �,' • • + • • I 2 � 1 certiPy that I have read this appiication and stale that the TOTAL FEE a- ': above intormation is correcL I agree io comply with all County '� ordinances and State laws regulating Electrical wiring, and ' .� � ,� 2 J� � � hereby authorize representatives of this County to enter upon 1�,SO�� th o -mentioned property fo inspection purposes. SEE�REYERSE FOR EXPLANATORY LANGVAGE � �--- �l .a"1 -go Si ture of Permitt Date � � �! � ' . � a , � � � z , \ ' ' , o � v ..� \\ � � o X � ° m � q � ` . , 2 `r '� 2 Z N. 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