HomeMy WebLinkAbout3372AWORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificateCE-806. of consent to self CE -806G
insure, or a certificate of Workers' Compensation Insurance, p COUNT
Y OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.,)
zk?VDO
Policy No.c'31�i-1.M - Compan 1.�rA
Certified copy is hereby furnished.New
Certified copy is filed with the county building inspec-
tion department.
r.
Date F -Applicant 542Ylr`
CERTIFICATE OF EXEMPTION FR V1 WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less.)
First 20
FOR APPLICANT TO FILL IN
Residential Bldgs. & oo
1 & 2 -Family, Sq. Ft.
Multi -family Sq. Ft.
Residential Swimming Pools
Outlets: Rec Light Sw.
First 20
Total No. , Additional
EACH
$
Fixed Appliances Not Over 1 HP
Range _ Heater_
D. W.
Oven —Dryer —
W. M. —
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
r(" ted 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.
pp
License Number 1 Lic. Class 10
E � C'
Contract Ft IiNt '9 Jate . x
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signatu
❑ 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 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 - tied property for inspection purposes,
ignature f Permittee Date
Lighting Fixtures
First 20
Additional
Total No.
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 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
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)_
JOB c
FEE ADDRESS,
FFLOCALITY
NEAREST
CROSS ST.
PERMIT FEE (Sub -Total)
PLAN CHECKING FEE
PERMIT ISSUING FEE /0 Sr
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
CITY(Tel. Noy
PLAN CHECK
APPLICANT
ADDRESS
CITY Tel. No.
PERMIT( / 1?a 1
APPLICANC T-JrLjAj //
CITY v�'}/i?jr Tel.
DISTRICT NO. PROCESSED
PROCESS BY
fC)
FINAL f
DATE Ib /�S� VALIDATION
FINAL
BY
2?5512A
2
1 ®®E5.86
1008-85
4�
OWNER-RLIILDEP DECLARATION
I hereby offirm 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 sign€d state-
ment that he is licensed pursuant to the previsions of the
Contractors License Low (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).:
El I, as owner of the property will do the work, and
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professicns Code: The Cootrac-
tor's License Low does not apply to an owner of property
who builds or improves thereon, and who does h
work himself provided that such improvements ai, of
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.
8 & P.C. for this reason
Date