HomeMy WebLinkAbout7956AWORKERS' COMPENSATION DECLARATION
I hereL'y 'affirm that I have a certificate of consent to self
11sure, ,, a certificate of Workers' Compensation Insurance, or
i certified copy"thereof (Sec. 3800, Lab. C
Policy NoL CompanN/'--
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection
department.
Applicant 4/6 10t "y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the work involved
)y the permit is for one hundred dollars ($100) or less.)
certify that in the performance of the work for which this
zrmit is issued, I shall not employ any person in any manner
as to become subject to the Workers' Compensation Laws.
ite— Applicant
OTICE TO APPLICANT: If, after making this Certificate of
xemption, you should become subject to the Workers'
,-)nipensation provisions of the Labor Code, you must forth-
ith comply with such provisions or this permit shall be
:emed revoked.
LICENSED CONTRACTORS DECLARATION
iereby affirm that I am licensed under provisions of Chapter
(commencing with Section 7000) of Division 3 of the Busi-
ss and Professions Code, and my license is in full force and
rect.
cense Number-2
Liq, Class
HOME OWNER -BUILDER DECLARATION
icreby affirm that I am exempt from the Contractor's
ense Law for the following reason (Section 7031.5, Busi-
;s 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
kereby affirm that there is a construction lending agency
the performance of the worl< for which this permit is
ied (Sec. 3097, Civ. C.).
rider's Name
rider's Address
ertify that I have read this application and state that the
ive information is correct. I agree to comply with all County
In' nces and State laws regulating Electrical wiring, and
eby authorize representatives of this County to enter upon
aocive-mentioned property for inspection purposes.
Signature of Permittee A, Date
76A663
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN J66
New Residential Bldgs. & Pools
EACH NO. FEE ADD 4
1 & 2-Family,Sq. Ft. $ $ LOCALITY
Multi -family Sq. Ft. NEAREST
Residential Swimming Pools CROSS STi fOWNER OR y,
r4
FIRM NAME
Outlets: Rec.—Light— Sw. MAIL
First 20 ADDRESS 6
Total No. Additional CITY bI Tel
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 60 Incl.
Over 50 to 100 Inc.
Over 100
Services
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)
APPLICANT
ADDRESS
CITY Tel No.rry
PERMIT
ER MIT
APPLICANT
LICANT t9 A,;V/�-, 4/G
ADDRESS
CITY Tel N./.
LICENSE OR ','_' REG. NUMBER' 2CIass
DISTRICT NO.
PROCESSED BY
1
L,171ei ,, 1
FINAL
DATE VALIDATION
FINAL
BY
9 7 9 5. A
c� t, 2
`)o
9_
ej 0
PERMIT FEE
PLAN CHECKING FEE (One -Fourth
PERMIT ISSUING FEE
TOTAL FEE
(Sub -Total)
Permit Fee)
0
SEE"REVERSE FOR EXPLANATORY LANGUAGE