HomeMy WebLinkAbout1721A (17) 1tiORKERS'COMPF,NSA7IONDECLARATION 76a663 APPLICAT{ON �OR ELECTRICAL PERMIT �
CEEO6G(2-801 c�� �
I hereby aftirm that [ have a certificate ot consent to self COUNTY OF LOS ANGELES ` BUILDING AND$AFETY u
insure,or a certificate of Workers'Compensation[nsurance,or - � . �
a certified copy thereot(Sec.3800.La6.CJ �,
j Policy No. Company FOR APPLICANT TO FIIL IN JOB y �(�� ',
EACH NO. FEE ADDRE /�7•�NI��� ,
New Residential 81dgs.&Pools '
�Certifed copy is here6y furnished. 1&2-FamilY.Sq.FL $ = $ LOCALIT
Multi•family Sq.Ft. NEAFEST
aert�i`te dci py i�filed with unty buiiding inspection Residential Swimming Pools /'• CROSS ST ,
P RMNAME ��, �/�,,
� Date�Apphwnt Outlets:Rec...-_Light Sw. A�DRESS�/ O�� - � <
�irs[20
CERTIFICATE OF EXEMPTION FROM WOR � 5' Totai No. Addinonal CIT -"f� 7ei No.
� COMPENSAYION[NSURANCE
. � " PLAN HECK a
APPLICART
(Thia section need not be completed if the work involved O
Ly the pe[mit is for one hundced dollus ($!00)or less.) Lighting Fixtures First 20 qooRESS V
Total No. <ldditionai �
i certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. Q
peimit i5 issaed,[shall nnt employ any person in eny manner - PERMIT V
. so as to become subject to the 19orkers'Compensation Laws. Range_Heater D.W. .. qpp��� ,.�.�('� W
Oven _.._.Dryer_W.M._ .� ' ��7 a
ADDRES � y
' Uate Applicant Top _FAU _W.H.._ " . �� z
Hood_Fan _Other_ Cf7V '�(�� Tel No. �
NOTICE TO APPLICANT:If,after making this Certi�cate of Disp. _Room Air Cond__ LICENSE OR ,.� �
�4 Exemption, you should become subjec[ to ihe Workers' REG.NUMBER / Class
� Compensation provisions of the Labor Cnde,you must forth- Power Apparatus&Large Appliances �ISTFICT NO. PROCESSED BY {
with comply with such provisions or this permii shall be Stze&Type HP,KW,KYA,or KYAR " a
! deemed revoked. '� � �" � �
� Up to 1 Incl, � u.ac.Erc.�
O�er 7 to t0lncl. FINAL
I LICENSEDCONTRACTORSDF:CLARA7ION DATE .L S/L . �
E Over 1Qto 501nc1. �2' � VALIDATION
j I hereby affitm that f flm litansed under provisions oF Chapter Over 50 to 700 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the Busi- BY �
E Over 100 � ���u��
ness and Professions Code,and my license is in fWl force and �
� effect. Services �
� 0-200 Amp.Under 600 V �
Licen • umbe Lic Class ' 207-7000 Amp.Under 600 V �
� Contra �te� � Over 1 WO Amp.or Ove�600 V j
i
HOhiE 0�4'NER-BUILDER DF,CLARAT[ON Temp.Power Pole&Appurtenances �
� I hereby aff'vm thxt 1 am exempt frum the Contractor's S�gn with One Branch Cireuit , �
License Law fvr the foilowing reason (Section 7031.5, Busi- Additional Sign Branch Circuits i
�i. ness and Professions Code): �� 7 2� A €
Misc.Conduits&Conducmrs �
� � [, as owner of the property,will do the work and the Other(See Complete Fee Schedulei—
structure is.not intended or offered for sate (Section #�• •�• • �2
� 7044,Business and Professions Code). 3
CONSTRUCTION LENDlNG AQENCY � � � •�3 S rJ O !
� 1 hereby affirm that there is a constructiun lending agency �
� f��r the perform nc af the work for which this permit is - • � ��J 8, 'rJ Q c�i �
PERMIT FEE fSub-Totatl
issued(Sec.309 i Q�0 3�'8 2
Lender's Name_, — PIAN CHECKING FEE (O�e-Fourth Permit Fee) .
LendePs Address PERMIT ISSUING FEE
I certify that t have read thi�application and state that the TOTAL FEE �� �
a6ove infotmation is correct.1 agree to compiy with all Coun[y
sdinunces and Sta laws regulating Electrical wiring, and
h�reby au or repr entatives of this County to enter upon
the above- enti ed p operty for inspection purposes. 1 SEE"REVERSE FOR EXPLANATORY LANGUAGE
Signature of Yermittee -��U
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