HomeMy WebLinkAbout9659AWORKERS' 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, Lab. C.)
Policy No. ��'2- Company S'idjl't F6A,64
❑
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
tion department. /
Date Applicant'1 e l'`' a_`ai
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.
Date Applicant
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
Contractors t -'v 14i, !d RAI -mate
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
❑ 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
I 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 N
Lender's Address
I certify that l 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 ty for inspection purposes.
AZ '5 7-~ &T
SignaturePer ittee Date
1D,8,
CE -806G APPLICATION FOR ELECTRICAL PERMIT
CE-t306
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
JOB
ADDRESS
New Residential Bldgs. & Pools
1 & 2 -Family, Sq. Ft.
EACH
NO.
FEE
$
—
$
LOCALITY
Multi -family Sq. Ft.
Residential Swimming Pools
Outlets: RecLightSw. i
First 20
Total No. AdditionalCITY
Lighting Fixtures First 20
Total No. 3 Additional
Fixed Appliances Not Over 1 HP /
Range_ Heater_ D.W. --Cl—
Oven —Dryer — W.M. —
Top _ FAU — W. H. —
Hood — Fan _ Other—LICENSE
Disp. — Room Air Cond.
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over 1 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Panelboards
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
1000 Amp. or Over 600 V
Power Pole & Appurtenances
with One Branch CircuitAdditional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)—
—
'NEAREST
CROSS ST.
OWNER OR
FIRM NAME G �f
MAIL
ADDRESS `' 1
1 Tel. No.
PLAN CHECK
,APPLICANT atm
ADDRESS
CITY Tel. No.
PERMIT
APPLICANT X YQ uo
ADDRESS
CITY Tel. No.
OR
REG. NUMBER Class.
DISTRICT NO./0
/Q
BY
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FINAL
DATE / �c/ VALIDATION
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PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
(Sub -Total)
y
_2s
,Z3
SEE REVERSE FOR EXPLANATORY LANGUAGE
10
APPROVALS
DATE
PECTOWS
ISIGN
SIGNATURE
TEMP. POWER POLE
UNDERSLAB WORK
ROUGH CONDUIT
WIRING
FIXTURES
ip
POWER AUTHORIZED
UTILITY CO. NOTIFIED
FINAL �ptfea orr �oRf
NOTES
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): Any city or county which
requires a permit to construct, alter, improve, demolish,
or repair any structure, prior to its Issuance, also re-
quires the applicant for such permit to file a signed state-
ment that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Profes-
sions Code) or that he is exempt therefrom and the basis
for the alleged exemption. Any violation of Section
7031,5 by any applicant for a permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars ($500).:
❑ I, as owner of the property will do the work, and
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor's License Low does not apply to an owner of property
who builds or improves thereon, and who does such
work himself provided that such improvements are not
intended or offered for sale. if, however, the building or
improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did
not build or improve for the purpose of sale.)
I am exempt under Sec. _,
B & P.C. for this reason
Date
Owner