HomeMy WebLinkAbout6986AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No. Company
11 Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
DataApplicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number LIC. Class
Contractor
I am exempt under Sec.
B.&P.C. for this reason_
Signatur
Date
Date:
Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code),
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes.
'SIgnature of Permittee Date
76A663 10/81
FOR ELECTRICAL PERMIT
CE -606G APPLICATION
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN JCB y�
ADDRESS � � -�� +�� ti .
New Residential Bfdgs. & Pools EACH NO. FEE t
1 & 2 -f=amily, Sq. Ft. $ — $ LOCALITY 4e.�'ri&axt�V�
Multi -family $q. Ft.
Residential Swimming Pools
Outlets: Rec Light Sw.7-
First 20
Total No. Additional
—
NEAREST
CROSS ST.
��'
�
�
OWNER OR n
FIRM NAME
ADDRESS 1 I-_-
CITY a._ ,- Tel. Na.�� -
1
1
PLAN CHECK
APPLICANT
Lighting Fixtures First 20
Additional
Total No.
ADDRESS
'1
CITY Tel. No.
Fixed Appliances Not Over1 HP
PERMIT
`Range _ Heater.—.. D. W. _
APPLICANT
ADDRESS
Oven — Dryer _ W.M. —
Top — FAU — W.H. —
Hood -..— Fan — Other
Disp. —Room Air Cond.
CITY Tel. No.
LICENSE ORREG. NUMBER Class.
Power Apparatus & Large Appliances
DISTRICT NO, PROCESSED BY
Size & Type HP, KW, KVA, or KVAR
P .l
FINAL
DATE VALIDATION)
FINALg
BY
Up to 1 Incl.
Over 1 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Et
Over 100
Services, Swbd., MCC & Panelboards
0 - 200 Amp. Under 600 V
1F�f L�
r ""`�---
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)—
PERMIT FEE
(Sub -Total)
3 Z
5
PLAN CHECKING FEE
PERMIT ISSUING FEE1
5
TOTAL FEE
APPROVALS
D '7 E
S I GN" A i Uir
1 r1 PO ER.PSI
UIIJDERSLA,� '010M
ROUGH CONDUt I'
FiXTUB RE -5
PO"LN FER U T HO P. I Z F D
U'-T!Vf7 C Nr-)TiF!ED
FINAL
N07FS
Ucanse Lo,,v for 'h�, c"o'soil r3acfioo 70j.1.5,
LY p�rv(W fa i !!sh,
or repnr fmv.
OW Ncensed �C- Nle
Coram olo.-'atact encfng
70001) Of Dlvi�k)n 3 Qr fl -a ind
S1.0ils cQde) 0r !hot he gip`
Tor fhe qlfeqt d cxemnp�', A- 5,70ion
yo
by Qml uppl!��xmf r r pem,0 lhv aPph-
c 29 L CiWSI pes?ehy *P no!
dc4iarz
aa -Dwnsr a4 iic c:o Hlu work, anCT'
flit Ilm Qf"5ars-n 1,C)F z,ds-
(Sec. 7N4, Co -61-: yl�c CGtI;rrc-
tor's Lica? se Lvw Qv'o,?�, Far p> rFjr
vii buF"j- or
'n, dcos Such
y"C' Such, Ore no;
ints,nrj4d ry H,,or�d` 'o,- s,moif? if, hov,,vver, r^ 1-,vilr'iecj or
not bvNe Q9- ifl-,'=� 1-1?;F,,DCSP OF
I cIrr C-,<em.pi under
B & 11,C- f-,.- !his rc-,a cn
Dule
Owner