HomeMy WebLinkAbout3160AWORKERS' 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 N dGompanylr'_,VSlO-
❑ 'Certified copy is hereby furnished. /iv oe/nN d7-ri
Certified copy is filed with the county building inspection
de rtme �f
Date �� . Applican ®✓ `Ju
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
NlTO APPLICANT: If, after making this Certificate of
EX. .cion, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION
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 '090VLic. Class r_/6
Contractor / /c/1
Date d
❑ 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 jy affirm that I am exempt from the Contractor's License Law
for ane 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 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
proper y for inspection purposes.
Signature of Permittee Date
76- 10/81
CE -806806G APPLICATION F® TR
LE
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO
FILL IN
JOB
ADDRESS, f'!3/ �O P
New Residential Bldgs. & Pools
1 & 2 -Family, Sq. Ft. _
Multi -family Sq. Ft.
Residential Swimming Pools
Q
Outlets: Rec �o Light _K Sw,�
�, First 20
Total No. 26 Additional
Lighting Fixtures First 20
Additional
Total No.. >7
Fixed Appliances Not Over 1 HP
Range_ Heater_ D.W. _
Oven _ Dryer _ W.M. _
Top — FAU _ W.H. _
Hood — Fan _ Other_
Disp. — Room Air Cond.
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
Up to 1 Inc].
Over 1 to 10 Inc].
Over 10 to 50 Incl.
Over60to 100 Inc.
Over 100
Services, Swbd., MCC & Panelboards
0 - 200 Amp. Under 600 V
'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)
EACH
NO.
FEE
LOCALITYT 36 !&
$ !i
—
$
n
—
NEAREST
CROSS ST,
l
OWNER OR�
FIRM NAME
MAIL � �v �� J
ADDRESS /
CIT�%�j�/ e� �jr7�oZ. Tel. No. � _
`
PLAN CHECK
APPLICANT.:.
ADDRESS.
CITY Tel. No.
PERMIT
APPLICANT✓�
ADDRESS,
CITY Tel. No �i6 161
LICENSE OR ,o 1
REG. NUMBER ' 7i l/ Class
DISTRICT NO.
PROCESS . BY
FINAL
DATE 1 G�1' VALIDATION
FINAL
BY
�.) ( 0 A
® a
t5
q
1 i
PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
(Sub Total)
0
SEE REVERSE FOR EXPLANATORY LANGUAGE
7
I0
as
OWNER-BUILDER.DECLAROON
APPROVALS
DATE
INSPECTOR'S
SIGNATURE
'
TEMP. POWER POLE
I hereby affirm that i am exempt from the Contractor's License
<.
„ Law for the following reason (Section 7031,5, Business .and
UNDERSLAB WORK
i Professions Code), Any city or county which requires a permit
to construct, alter, improve, demolish, or repair any structure, prior
a
ROUGH CONDUIT
to its issuance, also requires the applicant for such permit to 'tile
WIRING
f'ti
a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with
FIXTURES
-
Secfion 7000) of Division 3 of the Business and Professions
POWER AUTHORIZED
Code) or that he is exempt therefrom and the basis for the
alleged exemption. Any violation of Section 7031.5 by any
UTILITY CQ NOTIFIED
applicant for a permit subjects the applicant to a civil penalty
FINAL : Ehler on1 1"QPZ
N. -ar f of not more than five hundred dollars ($500):
.. ❑ 1, as owner of the property will do the work, and the
NOTES
' structure is not intended or offered for sale.
(Sec. 7044; Business and Professions Code: The Cc nrs
License Law does not apply to an owner of property wJ,_-,uffds
or improves thereon, and who does such work himself provided
that such improvements are not intended or offered for sale, ff,
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.)
am exempt under Sec.
B & P.C. for this reason
- Date
Owner