HomeMy Public PortalAbout10169 LOWER AZUSA RD_Electrical__ WC KERS' COMPENSATION DECLAR°BION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT
76A663
'I �wreby' cZgfirrp that I•bave a certificate of consent to self CE_806G
nsure, 0.=5 certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a cerified copy thereof (Sec. 3800, Lab. C.) t,
PohCY,No. 4F3 3 Company v,��e 1 FOR APPLICANT TO FILL IN JOB
/Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH rNO. FEE ADDRESS Q
LOCALITY
✓. $ $Certified copy is filed with the coun building inspec- 1 &2-Family, Sq. Ft. t
tion department. Multi-family Sq. Ft. NEARESTry
CROSS )
Residential Swimming Pools OWNEROR /
Date ApplicantVFIRM NAME
CER FICATE OF EXEMPTION O ERS' Outlets: Rec Light Sv, AMAIL
DDRESS
COMPENSATION INSURAN First 20
(This section need not be completed if the work involved by Total No. Additional CITY � el. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT 1/11 IR
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION t
Exemption, you should become subject to the Workers' Range— Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. — /J
deemed revoked. Hood — Fon —Other, CITY (,(� Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. _ REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO < RROCE5SED B
< and Professions Code,and my license is in full force and effect. O
Q Size &Type HP, KW, KVA, or KVAR
-License Number Lic. Class /0 Up to 1 Incl. FINAL B U
L �IS+ �� ;