HomeMy WebLinkAbout1574A (9)WORKERS'COMPENSATIONDECLARAT[ON
CE-806G 12-B01 APPLICATION FOR ELECTRICAL PERMIT
E-906
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAF
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy Athey ofQ(Seec. 3800. Lab. C.
Policy No. 7t% /Co npany S i
El Vtiled copy is hereby furnished.
copy is filed with he county�build*nspion
I department.
Date Appltca
I CERTIFICATE OF EXEMPT FROM WORKERS'
COMPENSATION INSURANCE
FOR APPLICANT TO FILL IN
New Residential Bldgs. & Pools
1 & 2-Famil S Ft. Yq•ified
Multi -family Sq. Ft.
Residential Swimming Pools
Outlets: Rec2Light� Sw. I
First 20
Total No. Additional
EACH NI
a 7S 'I
(This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.)
that ithe performance of the work for which this
1 permit
permit b issued,, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Lighting Fixtures First 20
g g Additional
A
Total No.
Fixed Appliances Not Over 1 HP
Range— Heater_ D.W. _
s `
Oven _ Dryer _ W.M.
Date Applicant
Top _ FAU _ W.H. _
Hood _ Fan _ Other
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Disp. _Room Air Cond—
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
Power Apparatus &Large Appliances
Size & Type HP, KW, KVA, or KVA
I Up to 1 Incl.
i
Over 1 to 10 Incl.
LICENSED CONTRACTORS DECLARATION
Over 10 to 50 Incl.
l f hereby affirm that I am licensed under provisions of Chapter
Over 50 to 100 Inc.
9 (commencing with Section 7000) of Division 3 of the Bus!-
ness and Professions Code, and my license is in full force and
Over 100
effect.
-7 7 6 -76 Lia Ctass C/o,
License Numb
.. ContraetoNl!er) 7Data/6-s- / �F . Data/6- — —7
Services
0-200 Amp. Under 600 V
201-1000 Amp Under 600 V
Over 1000 Amp. or Over 600 V
HOME OWNER -BUILDER DECLARATION
Temp. Power Pole & Appurtenances
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
Sign with One Branch Circuit
Additional Sign Branch Circuits
ness and Professions Code):
El 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
Misc. Conduits & Conductors
Other (See Complete Fee Schedule) —
'I044, 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.).
PERMIT FEE (Sub -Total)
Lender's Name
PLAN CHECKING FEE (One -Fourth Permit Fee)
Lender's Address
PERMIT ISSUING FEE
1 certify that I have ad is ication and state that the
TOTAL FEE
avWve-m'
e
e to comply with all County
tingElectrical wiring, and
f this County to enterupon
anspection purposes. 7
Signature of Permittee Date
JOB FEE ADDRESS o,-/07.3 /�Tll- FlzvoF
LOCALITY
CROSSST [�
OWNER OR A ,
FIRM NAME MAIL
t��I!`
\ `I ADDRESS 17 p es
CITY t--L_ Tel No.
PLAN CHECK
APPLICANT
ADDRESS
CITY Tel No.
PERIT
APPLICANT )� 7 zi
ADDRESS 17ky.2 TG1
-A
CITY f _./jyu— a Tel No4f7 L(-']7/
SEE REVERSE FOR EXPLANATORY LANGUAGE
DISTRICT NO. IPROCESSED
TE VALIDATION
IAL
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