HomeMy WebLinkAbout1744A (17) WORKERS'COMYENSATIONDECLARAT101V 76A663 �
�E$os��z.eb, APPLICATI4N FQR ELECTRICAL PERMlT �
t hereby atfirm that 1 heve a cnrtiGcate of wnsent ta se[r • COUNTY OF tOS ANGEtES _ BUILDING AND SAFETY '
insure,or a certificate ot Workers'Compensation[nsurance,or ' ��,
, e ttrtitie�opy Yhepreof(Sec.3800>Lab._C.) . �� - � -
O�— �'�'�"�'— FOii APPLICANTTO FILL IN n� // p�� �
� Policy N .��.� Company-�'�-TC� New Residential Bldgs.&POols EACH NO. FEE D�REss.[����/c-L(.O�(f6i
� Certified copy is hereby furnished. i&2•Family,SG,Ft. $ — $ LOCALIiY
OMulti-fam4ly Sq.Fi. — NEAREST
Certified cupy u filed with the caunty buiiding inspection CROSS ST
�p��I„�_ � � Residentiat Swimming Pools OWNER OR /0, t�,���1�
DatcJ 8y'�/ v`� FiRM NAME /v 4./ (T�
n' � / Applicant Outle s:Rec._Lfght.____Sw._ MAIL /
First 20 ADDRESS �p �(��l
CERTIFICATE OF EXEMYTION FROM WORKERS' Total No. Additional CITY�- Tel No �_ f �
COMPENSATIONINSUKANCE
� � � PLAN CNECK � a
(This section need not be compteted iP ihe woik ii�volved APP��caNr p
Li htin Fixtures First 20 V
. 6y d�e permi[ is for one hund[ed d011ars(5100) oc less) 9 9 Additional ADDRESS
' Totaf No. ¢
. I certify that in the performance of[he work for which[his CITY Tel No. Q
ermit is lssued,I shall not em lo an Fixed App�iances Not Over 1 HP f..
P p y y person in any manner PERMIT (� /� U
so na to become subject to the lyorkers'Campevsation Laws. Range_Heater D.W._ APPLICANI..,�� !� a €
-- OVBn _�fy¢f_W.M._ ADORESSS�IB CI�Nr� Z �
Date Applicant , Top _FAU _W.N._ r _ �
Hood—Fan _Other_ ��TYJ� Q//��'� T��No.,� -933 �
NOTICE 70 AYPLICANT:If,afhr making this Certificate of Disp. _Room Air Co�d._ LICENSE OR
£xamption, yau should become subject to ihe Workers' REG.NUMBE��J�Class e��� 3
Compensation provisions uP the Labor Code,you mast forth- power Apparetus&Large Appliances DISTBtC7 NO. PROCESSEO BY �
with comply with such provisions or this qermit shall be
deemed revoked. � Size&Tvpe NP,KW,KVA,or KVAR /Q ��v i�
Up to 1 tncl. FINAL 7
over t to to tac�. VALIDATfON
LICENSE�CONTRACTORS DECLARATION � DATE 1
3
Over i0 to 50 incl. S
1 hereby affirm that I am(icensed under pmvisions of Chapter Over 50 to 100 Inc. PtNAL �
9 (commencing with Section 7000)of Division 3 of the Busi- BY �
Over 100 !
ness and Rofessions Code,xnd my license is in fuU force and . d
effect. Services �
License Numb�,i �� Lic.�Class �;� �'200 Amp.Under 600 V �
�J ' p../�._ � �7 �,/ 201-1000 Amp.Under 60U V �
Cnntractor�LGLI Ot�Date_ S� Over 1000 Amp.or Over 600 V
HOME OWNEH-BU[LDER DECLARATION Temp.Power Pole&Appurtenantes �
- I hereby affvm that I am exempt from the Contractor's
Sign with One Branch Circuit �=� ��4 A
License Law for the following reason (Section 7031.5, Busi- AdditiOnat Sign Branch Circuits � � o r-� 0 2
= ness and Professions Code): �
Miu.Condui[s&Conductors � m •���C E
, � 1, us owner of the property,wilt do the wurk and the Other(See Complete Fee Schedulel— �
structure is not intended or offered for sale (Section • e •5 Q,5��
T044,Busineas and Professions Code). C�2 2%�G 4 �
CON5TRUCTION LENDING A(,ENCY �
I hereby affirm.that there is a construction lending agency ' ,
for the performence of the work for which this permit is pERMiT FEE , �Sub-Tatall �
issued(See.3097,Civ.CJ. o �
Lender's Name PLAN CHECKING FEE iOne-Fourth Permit Fee) ,
Lender's Address PERMIT ISSUING FEE �
�
I certify ihat t have read this application and state that the TOTAL FEE �p �
above information is cotmct.[agree to comply with ail County
ordinances and State laws regulating Etecttical�widng, and �
hereby suthorize representatives of this County to enter upon . `�
the above-mentioned property for inapecNon purposes. SEE�REVERSE FOR EXPLANA'CORY LANGUAGE
- �!��a�'�— .��7-8� ,
�gnature of Permittee Date � � �
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