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 �
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