HomeMy WebLinkAbout9536AWORKERS' 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 thero.of (Sec. 380QLab. C.)
1
Policy No, Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed ,with the county building inspection
department. I
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.
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 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
LiC. Class
Contractor Date
❑ I am exempt under Sec,
BAP.C. for this reason
Date:
Signature
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLAHATION
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions
Code):
❑ 1, 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
informalion 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
Signatureof Permittee
Date
76.883 '0'81
Ci= -606G APPLICATION FOR ELECTRICAL PERMIT
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
$
—
S
Multi -family Sq. Ft.
Residential Swimming Pools
Outlets: Rec Light Sw.
First 20
Total No. Additional
Lighting Fixtures First 20
Additional
Tota! No. '
Fixed Appliances Not Over 1 HP
Range_ Heater_ D.W. _
Oven Dryer W.M. _
Top FAL 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)
NEAREST
GROSS ST.
OWNER OR
FIRM NAME
MAIL
ADDRESS
CITY Tel. No.
PLAN CHECK
APPLICANT
ADDRESS
CITY Tel. No.
PERMIT
APPLICANT..
ADDRESS
CITY Tel, No.
LICENSE OR
REG. NUMBER Class.
DISTRICT NO.
PROCESSED BY
FINAL
DATE
VALIDATION
FINAL
BY
,
i • R • r .
► t
PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEF
(Sub -Total)
SEE REVERSE FOR EXPLANATORY LANGUAGE
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