HomeMy WebLinkAbout9323AWORKERS' 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,Laal. C.)
Policy No. � �"� Company R d
Certified copy is hereby furnished.
Certified copy is filed with the count 'Iding inspection
department_ ..
Date Applicant C
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(This section need.not be completed; if the work involved by the
09.rmit is for one hundred -dollars ,[000) or less.)
1 certify that in the performance of •the work for which this.:.permit
is; issued, .I shall not employ any person in any marine(.,.so, as to
become subject to the Workers' Compensatioonn�L
Date L 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, forthwith 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 a_/ / _Z -7/r Lic. Class lJ
(su iT
Contractor a S K >f w° Date �� Z
.❑ I am exempt, under Sec.
B.&P.C. for this reason
fDate:
Signature
❑ Exemption for Reg.
HOME OWNER -BUILDS DECLARATION
I hereby affirm that I am exempt from he Contractor's License Law
for the following reason (Section 7031. , Business and Professions
Code):
❑ 1, as owner the property, will do the ork and the structure
is not inten0ed or offered for sale (Sec 'on 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
1 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)"nspectio urposes.
•'-2-�
Signature of Permittee Date
76-663 10,61
CE -8060 APPLICATION FOR ELECT ICAL PER
COUNTY OF LOS ANGELES
,,,BUILDING AND SAFETY ,t
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
s
Outlets: Rec Light SW.
First 20
Total No. Additional
Lighting Fixtures First 20
Total No. � Additional
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
AdditionalSignBranch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)
—
NEAREST
CROSS ST,
/I
OWNER OR
Ku.
MNAME GS+mei v
MAIL y t ! 3 S� k w �� INV -
ADDRESS
-c�
CITY .. �Qto,u C �,�, Tei. No. Z
PLAN CHECK f
APPLICANT S
ADDRESS '
CITY ;i �L+ T Tel. No. r: ')
PERMIT (,
APPLICANT li' (� \ `f- K-3
ADDRESS t ?� �� 4,v : J
CITY Tel. No.�
LICENSE ORClass.
REG. NUMBER J 2- _7))
DISTRICT NO.
OCESSED Y
FINAL .
DATE
(VALIDATION
FINAL
,BY
N
h, �. =
( i R. j
s
-
PERMIT FEE
PLAN CHECKING FEE
PERMITISSUINGFEE
TOTAL FEE
(Sub -Total)
lE/
`L1
SEE REVERSE FOR EXPLANATORY LANGUAGE
I•
APPROVALS
DATE
INSPECTOR'S
CGNAI URE
TEMP. POWER. POLE
UNDERSLAS WORK
ROUGH CONDUIT
em
WIRING
FiYTURES
POWER AUTHORIZED
{
----
UTILITY CO. NOTIFIED
FINAL Enter on Front
APPROVALS
DATE
INSPECTOR'S
CGNAI URE
TEMP. POWER. POLE
UNDERSLAS WORK
ROUGH CONDUIT
WIRING
FiYTURES
POWER AUTHORIZED
{
----
UTILITY CO. NOTIFIED
FINAL Enter on Front
.F #a IJ M ua vvvi icy vi u�a Pup—Y uu 11 r v111 rc, ttnu U 1
NOTES
structure is not intended or offered for sale.
. d Professions Code. The Contractor's
.. {Sec 704 Business an
License Law does not apply to an owner of property who builds
or improves thereon, and who does such work himself provided
f----– — — -- 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.)