HomeMy WebLinkAbout0131A WORKERS'COMPENSATIONDECLARATION �aA�� �o�e, APPLICATION FOR ELECTRICAL PERMIT �
I hereby a(firm that I have a certifico�e of consent to self CE-B06G
insure, r a ce��iiicate of Workeri Compenso�ion Insorance, COUNTY OF LOS ANGELES � BUILDING AND SAFETY
or a ertified copy thereof(Sec.3800C,lorb.fCI..,),�,._ � �, i
olicy No. Compony—d/'T/�r v� FOR APPIICANT TO Flll IN ��B a �� I G�
� Ce�tified copy is hereby furnished. EACH NO. FEE A �RE55
. New Residential Bldgs.8 Pools
ertiiied copy is(ited wilh the county boilding inspeo- 1 8 2-Family,Sq.R. s — S LOCALI Y �
ian department. Mulli-fomily Sq.FI. — NEAREST
CRO$$$T.
Residential Swimming Pools OwNER OR •�
Date Appii[ont /� �J iIRM NAME �
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets-RecJ_[_Ligh��!Sw.� �'��
COMPENSATION INSl1RANCE First 20 A�DRE55
(This axfton nead nof b.cemple»d if th.work involvad by To�al No.� Addiiional CIN Tel.No.
tA�p�rmit(s for o�o hundr�d dollars(Z100)or Iss�.j a�aN CHECK
I cerfify that in Ihe perfarmonce of Ihe work for which ihis PPIICANT '
_ permit is issved,I shall not employ vny person in any monner _
so as to become subject to the Workers'Compensotion taws. lighting Fixtures � First 20 ADDRESS
� Totol No.� '�`dditional
Date- opplicont CITY Tel.No.
NOTICE TO APPLICANT: If, after mokfng �his Cerfifitote of Fixed Applionces Not Over 1 HP PERMit
E�emption, you should become subject to ihe Workers' Ronge_Heoter_D.W._ APPIICAM r
Com�nsnHon p.ovis�ons of rhe Labor Code,yov mvs�forth- Oven _Orynr _W.M._ .O• O b
with comply with svch provisions or this permif sholl be Top _FAU —W.H.— �1
deemedrevoked. Hood _Fan _Other_ ��N Te t� � p`
IICEN$ED CONTRACTORS DECLARATION UCENSE R �
I heraby offirm thot I om litensed�nder provi:ionz of Chapter 9 Disp. _Room Air Cond. — y p� CIaSS. O
REG.NUMBER
(commencin ith Section 7000)of Division 3 of Ihe Business DISTRICT NO. D 8Y p�,' �
and Profes" n Code,ond my hcense is in full force and affecL Power Apparotus 8 large Appliontes �
Q /"� Size 8 Type HP,KW,KVA,or KVAR� , U
— license um v LiC.Class �+ � Up to 1 Ind. � FINAI . d.' -_
Contrac� Date Q Over 1 ro IO lnd. DATE . �Z'3�� VALIDATION �.
❑ .Over lO to 50 Incl. FINAL
U
I m exempt�nder Set. Over 50 to 100 Int. BY � O:
Over 100 �
8.8P.C.for�his reason . Z
— Date: Services,Swbd.,MCC 8 Panelboards � ._
0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V �Q� �j.� {�
� �`Exemption for Reg.Maint.Elect. , ,
SINGIE FAMILY Temp.Power Pole 8 Appunenances �� � ��� �2
HOME OWNER-BUILDER DEGLARATION Sign wi�h One Bronch Circuit �� • •4 7.2 5
I hereby affirm tho�I om exempt from the Controc�or's License Additional Sign Bronch Circuits
Law for the following reoson($ection 7031.5,Bosiness and y'e •4 7.2�� .
Proiessions Code): � � .
� Misc.-Conduils&ConduUors .
I,as owner of the property,will do the work and the '����,�1 8-8 b ,
struc�vre is not iMended or oife�ed for sale($ection Other(See Compleie Fee Schedule)_ , �
7044,Business and Profeszions Code).
CONSTRUQION LENDING AGENCY �
1 here6y affirm�hat there is a consfrucfion lending agency for
the pertormante oi the work ior whkh ihis permil is issued PERMR FEE � � (Su6•Total) 3 � - � -
(Sec.3097,Civ.C.).
' PLAN CHECKING FEE � � �
� tender's Name �
i PERMIi ISSUING FEE � � - -
Lender's Address �
I c �y thor I have read this applimfion and srme fhm fhe TOTAL FEE � ?2 •�
ab ve i formation is correct. ree fo comply with oll County � �
o in es ond Stat gulating Electrical wiring,and . �
ere uthori entmives of fhis County to enter upon � �
e-m ed properfy for inspeciion pur ses. j ,
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
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