HomeMy WebLinkAbout0046A WORKERS'COMPENSATION�ECIARATION � � `soaivow+aie� APPLICATI4N FOR�ELECTRICAL PERMIT Q �
I hereby affirm ihat I have o certificme oi consent io sell. ��� �
insure,or a certifica�e of Workers'Compensation Insuronce,: COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
or a ceriified copy ihereof(Sec.3800,Lab.C.) � ��
PoliCy No. Compony � fOR APPLICANT TO FlLL IN I JOB .
���,JC�erfiiied copy is hereby furnished. � . '� New Residential Bldgs.8 Pools EACH NO. FE[ ADDRE55 .� 7
�1XCertified co a iiled with the wunt buildin ms et-�� 1 8 2-Famil F. 5 = S I LOCA�ITY
1X PY� Y 9� P Y.Sq_
kv tion deparlmenl. I Muhi-family Sq..Ft: � CRO55 ST.
Residentiol Swimming Pools � OWNER OR �'/
Dofe Appiiconl - j FIRM NAME L!�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Ligh�_Sw.__ ���
-COMPENSATION INSURANCE ! � nD�RESS
(Thii�ecfion n��d nol be complafad if the work tavolvad by� Firs1 20 CITY 'Tel.No.
the parmtt is For one huedrad dollors(f1D0)or lass.) - To�al No. Addi�ionol �
PLAN CN K
I certify that in:he performance of�he work for which ihtsl � qeFl.ICANT
permi�is issued,I sholl not employ any person in ony manner� ��9h�ing Fix�ures First 20 ADDRESS
so os to become so6ject to the Workers'Compensotion laws.� �
Additional
r Total No. CITY Tel.No.
Date /�� ' pplimm � Fixed Appliontes Not Over 1 HP P[RMII � w�1
NOTICE TO APPLICANT: If, ofter moking this Cerlificole of APpLICATION i'!
Exempiion, you should 6ecome subjecl to Ihe Workeri Range_ Heater_D.W._
Compensation provisions of the Lobor Code,you must forih- Oven —Dryer —W.M.— ADDRESS .
with comply with such p�ovisions or ihis permil shall be Top —FAU —W.H.—
deemedrevoked. � � � Hood —Fan �—Oiher_ CITY Te11�Q�- � �
LICENSED CCVTRACORS DECIARATION uCEnSe Ce
I hereby alfirm Ihat I am Ifcensed under provisions of Chapter 9' D�Sp. _Room Aif ContJ. — REG.NUMBER 3 Class �
(commencing with Seclion 7000)ot Division 3 of the Business- Power Apparo�us 8 Large Applionces DISTRICT NO. PROCESSED BY a
and%ofessions Code,and my license is in full force and effect.� �
Size 8 Type HP,KW,KVA,or KVAR O �" �
/��l/� U
litense Number � Lic.Class� � Up l0 1 Incl. FINAL �
.��.�� /� Over 1 to 10 Ind. DATE � �J'2� VpLIDATION p
Contractor pofe.r7 � � Over 10 to 50 Ind. �t
❑ FINAL ~
I am e.empt�nder Sec. Over 50 10 100 Inc. BY W
8.8P.C.for ihis reason � Over 100 �
� _ Services,Swbd.,MCC 8 Panel6oards � ' Z
a1e:i 0-200 Amp.Under 600 V �
Signotore 201-1000 Amp.Under 600 V <Q��.6 A .
❑ Over 1000 Amp.or Over 600 V '
Ezemp�ion ior Reg.Maint.Elect. �i• • � � �2
SINGLE FAMIIY � Temp.Power Pole 8 Appunenances ( • •5 5.5 0
HOME OWNER-B�IIDER DECLARATION Sign with One Bronch Circui�
I hereby offirm thot I om exempl from the Conimclor's License qdditional�i n 6ranth Circuils ' ' •�h��=n J
Law for fhe fotlowing reason(Section 7031.5,8usiness ond� "9
Professions Code): 0 7 2 1 —8 8
❑I,as owner of ihe propeny,will do the work and the� Mist.Conduils 8 ConduUo�s
shotture is not inlended or oF(ered for sale(Setlion 7044, Other(See Complete Fee Schedule)_ �
Business and Rofessions Code). "
CONSTRUCTION IEND�NG AGENCY ' �
I hereby atfirm that Ihere iz a construciion lending agency(or�
�he performance of the work for which this permit is issued PERMIT FEE -�� (Sub-Tatal) C�
(Sec.3097,Civ.C.).
� � � � PLAN CHECKING FEE
Lender i Name PERMIT ISSUING FEE �6
Lender's Address �� TOTAL FEE �
I certify�hat I have reod this applicotion ond s�a�e that the'. S.� '
obove iniormo�ion is correct.I agree to comply with all Counly'�, . .
ordinantes and Stole laws req�loling Electricol wiring,and �
hereby auihorize representatives this County to emer upon!
t/he a1bove-mentioned propeny inspectian purposes. ' ' SEE REVERSE FOR EXPLANATORY LANGUAGE
��/f� � .v %�l� ; o.
Signalure of Permiftee —�Date � - ,
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