HomeMy WebLinkAbout0176A WORKERS'COMPENSATIONDECLARATION ;�6A�3 ,o�e, APPLICATION FOR ELECTRICAL PERMIT �
I here6y affirm that I ho�e a cerfifica�e of consent lo self .CE-006G �� �
insure,oi a cenHiro�e af Workers'Compensotion Insurance, COUNTY OF LOS ANGELES ' BUILDING AND SAFETY '
o�a certified copy thereot(Sec.3800,Lab.C.)
Policy o.��COmppny ��_ FOR APPLICANT TO FILL IN JOB ,�/,ry
Cerfified copy is hereby furnished. New Residentiol Bldgs.8 Paois EACH NO. FEE A�DRE55�J�. �It
� Certified copy is filed with Ihe counly building inspec- �g 2-Fomily,Sq.Ft, S — E IOCALITY
NEAREST ����Rp,.r��' �
fion deparfinent. MuNi•fomily Sq.FI. CRO55 ST.a�tl-���[ �
o-� Residentiol Swimming Pools OWNER OR
Da�e Applicanr j� FiRMNAME 'r ! L�
ERTIFICATE OF EXEMPTION FROM WORKERS' � - htqi�
COMPENSATION INSURANCE Outlets:Ret ght_Sw._ ty nDDaE55
First 20 �
(Thls��tfien naod not ba tomplat�d II�h�work invelv�d 6y Tolo�No.� Additional CITY � o. �
1h�p�rmlf I�for ona hundred dollan(5100)or Iss�.)
I certif �hol in the erformance of the work for which this PtANCHE �
permit�s issued.I shall not employ any person in ony manner APPIICANT
so as fo become subjecf to the Workers'Compensotion lows. Lighting Fixtures First 20� ADDRESS �
� Totol No. Addilional �
Do�e epp�;�e�� CIN Tel.No.
NOTICE TO APPIICANT: If, aRer making this Certifimte of Fixed Appliances Not Over 1 HP pEgMiT
Exemption; you should become subject to �he Workers' Range_Hea�er_D.W._ A����'�T � �
Compr.nsation provisions of the Labor Code,you must forih- Oven _Dryer _W.M._ ADDRES�y�7� � �
wilh camply with such provisions or this permit shall be Top _FAU —W.H.—
deemed revoked. CITY Tel.No.'� tL
LICENSED CONTRACTORS DECIARATION Hood _Fan _Other_
Dis _Room Air Cond. � UCENSE OR ��j y� Class�i(�
I hereby affirm thaf I am licensed under provisions of Chop�er 9 p' REG.NUMBER T j�ir/
commencin �h Section 7000 of Division 3 of the Business 4
� 9°" � Power Apparolus 8 Large Appliances DISTRICT NO. .. � � PROCESSED BY
and Profession:Code,ond my license is In full forte and eHetf. �'
A�'/� ��� Size 8 Type HP,KW,KVA,or KVAR� l O U
license Number�i�L�`ti1_ZLia Cbss Up to 1 IncL FlNAL �
CoMrac�or �f �� ��/��� Over 1 to IO lncl. DATE - �U� yq��DAT10N ��
�f�'L'1._ Dole-4`=f-� Over 10 to 50 Incl. W
FINAI
, �am e.emp�under Sec. Over 50 io I00 Inc BY �.'
Over 100 N
B.BP.C.for�his reoson Z
Dote: Servites,Swbd.,MCC 8 Ponelboords � "�
0-200 Amp.Under 600 V
$ignature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 60p V • �
Ezemp7ian for Ret�.Moint.Eled.
SINGIE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUIIDER DECLARATION Sign with One Branch Circuit
1 hereby afiirm that I om exempt irom the Controc�or's license Addi�ionol Sign Bronch Circ�iis r.
Law/or the following reason(Sectian 7031.5,Business ond �O� �6 A
Professions Code):
❑ I,as owner of the property,will do the work and the Mis4 Conduits 8 Conductors . �.s � e • �2
sfr�[�ure is not intended or offered for sole(Sec�ion O�her(See Comple�e Fee Sthedule)_ ► .
7044,Business and Prolessions Code). � • • � �7,2 Jr
GONSTRUCTION LENDING AGENCY '°�a � G.C S u-
I he�eby offirm th�t�here is a conshuction lending agency for
the performonce of the work for which this permit is issued PERMIT FEE (Sub-Totol) ��,2 9�8 6
(Sec.3097,Civ.C.). -
� PLAN CHECKING FEE �
Lender's Name �
PERMIT ISSUING FEE � �
Lender's Address
I certify�ha�I have read this applicotion and sbte that�he TOTAL FEE . . . . .
above information is correct.I ogree�o comply with all Co�Ny
ordinantes ond Sta+e laws reguloting Electrical wi�ing,ond .
he�eby a orize represen�otives of ihis Co�Ny�o enter�pon �
the eniio d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�I / �Y
Signoture ef Permittee Dote
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