HomeMy WebLinkAbout1858A WORKERS'COhiPEN5AT10NDECLP.RA7lON ? �6Afi63 �APPUCATION FOR �ELECTRICAL PERMIT
- � CE-BO6G 12�60) ' �
I hereny atfirm that I have a cenificate ot consent to se�f� COUNTY OP LOS ANGELE� BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or , � _ /
a certipfi�e,�d cop [hereofR((55 ec.3800,Lab.C.) � S�r
D�w�,��d`7,J � � FOR APPLICANTTO FILL IN Jpg /O 1 �
� Policy No. "Compan ADDRESS (O �
New Residential Bldgs.&Pools EACH NO. FEE
� CertifieJ copy is hereby furnished. 1&2-Famiiy,Sq.Ft. $ `" $ LOCaLi7V Q
� Mul[i•family Sq.Ft. — NEAREST � �C
Certified copy is filed with the county building inspection cR055 ST
depart en � Residential Swimming Poo15 OWNEFi OR �
v�j �7 - � ' FIRM NAME
� Date 0 ApP�fcant � Outlets:Rec.L Light.I=Sw.� � 0 qODRESS ^ L'
' CERT FICATE OF EXEMPTION FROLt WORKF.RS' First 2
� Total No.�� Additional CITY ,r Tel No.
. COMPCNSATION[NSURANCE ' PLaN CHECK }
� APPLICANT� 0.
(This section need nat he completed if the work involveJ `� �
by the permi[ is for one hundred dollara (3100)or leas.) Lighting Fixtures Pirst 20 qDORESS V
Total No.� Additional � .
I certity that in the performance of the wnrk fnr which this Fixed Appliaaces Not Over 1 HP CITY . Tei No. � O
permit is issued,1 shall not employ any person in any mannet pERMIT �
sn as to become subject to Ihe Workers'Cnmpensation Laws. Range_Heater D.W._ APPLICANT �YA-C I,UI,)
- OVen ^Dfyer_W.M._ � ADDRESS ^L Q �t� � y
7op _FAU _W.H.._ z
Date - ADP���ant .
H�d_Fan _Other_ CITY � � ..Tel No.`�� 'y8
NOTICE TO APPLICANT:ff,afler making this Certiflcate of Disp, _Room Air Cond� LICENSE OR i /�
Exemptlon, you should become �subject to the Workers' REG.NUMBER � ZTms !S
Compensntion pmvis�ans pf the Labnr Code,you must forth• power Apparetus&Large Appliances DISTFiICT NO. PROCESSED BY _
with comply with suth provisions or this �ermit shall be Size&7ype HP,KW,KVA,or KVA �
deemed revoked. . '`O
. ' UptollnCl. PINAL -
� Over 1 to t0lnel. DATE � �� y
GICF.NSC•DCONiRACTORSD@CLARATION ' Over10ta501nc1, �f.3 VALIDATION '
1 hereby affirm that 1 am licensed unJer provisions of Chapter Over 50 t0 100 Ina FINAL . �
9(commencing with Section 7000)of Division 3 of the Busi• Over 100 BY
ness and 1'rofessions Code,and my license Is in tull force and -
eftect.�.��7/q j �l . Services � � . �
S_c,�.i v �,�
License Nu er Lic.Class 0-200 Amp.Under 600 V
201-1000 Amp,Under 600 V
Contractor�_ Date �Z~ Wer 1000 Amp.or Over 600 V � . _
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenanees , �
1 hereM1y affirm ihat I am exempt from the Contractot's S'g^with Qne Branch Cireuit _
License Law for[he foltowin¢reason lSection 7031.5,�.pusi- Additional Sign Braneh Circuits �-4 1 R�R n
nessandProfessionsCode): � . ' - ��•.� ����,�2 , .
Miu.Conduits&Conductors '
� 1,as owner of the property,will do Ihe work and the Other(See Complete Fee Schedulel— �
structure is not intended or otfered for sale (Section � •�'2�9 0
7044,Husiness and Professions Code). • �
CONSTRUCTION LENDING ACENCY •',• •P H.9 O� � -
I hereby affirm that �here is a constructiun lending agency ' � � '
for the performance ot the�vork for which �his permit is � pERMIT FEE ISu6-Tota1) ��� 6"II 2
issued(Sec.3097,Civ.CJ. � . 4 a , -
Lender's Name PLAN CHECICING FEE (One-Fourth Permit Fee� .
Lender's Addrcss PERMIT ISSUING FEE - - �
I certify that 1 have read Ihis application and state that the TOTAL FEE � a .
above information is correct.I agree to comply with all County ; ..
nrdinances and State la�s•s regulating Clectrical�viring, and ' �
hereby authorize re resentativ of Ihis County to enter upan . - - �
the a me�ment' ed prope for inspection purposes. : • SEE'RL•VERSE FOR HXPLANATORY LANGUAGB � � '
Signature of P mittee �le �L— � ' � , �
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