HomeMy WebLinkAbout0506A (4) � WORKERS'COMVENSATIONDECLARATION �e�� io�e� APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm �ho�I have a ceriifimte of consenl to self �'�� � .
insure,or a cerrificoie of Workers'Compensotion Ins ante, COUNTY OF LO$ANGELES BUILDING AND SAFETY
�o certifiad��cQo/py t�he/r/ep f(Sec.3800 .)
��.P�oli[y No._�N/V_,�Compon � FOR APPUGNI TO FllL IN !OB
Certified copy is hereby furnished. New Residential Bldgs.&Pools FACH NO. FEE �R� �, d
-�erfified c is filed wilh the count buildin ins - LOCALITY �
o0Y Y 9� Pe�- 1&2-FamilY,SG.Ft. s — s �,Q�
NEAREST
tion eporl em. -� _� Muhi-familySq.FL CRp555T. /j
' � � Residential Swimming Pools A,.
�pole �`� APPlicanl � � FIRMENAME L.!!
� CERTI ICAiE OF E%EMPiION FROM WORKERS' Outlets:Rx—ligh�_Sw._ �"w'�� � �j
� - COMPENSATION INSURANCE A��u
7h1���clion nNd nof b�eom �eMd I!th�work involv�d b first 20
P � Tolal No. Additional� CITY Tel.No.
he permit k(or ons hundnd dallen(=100)or lass.) �
'certify Ihat in�he performaace of the work fw�whith Ihis qp�p�KjpjTK �
�ermit is iuued,I shall not employ ony person in any mpnner- � ^
o as�o become subject io the Workrs'Compensalion Laws. Lighting Fi�.tures Fire�20 ADDRESS � 6�r
�� - Total No. �+dditionol -
5te epplicant - � CITY �r�— Tel.Mo. �,.t�y(,
OTICE TO APPLICANT: If, after making this Certificate of FiKed Applion[es Nol Over 1 HP - PERMIT �
emption, you should bacome subject lo the Workeri . Range_HeaMr_D.W._ AVttIUNT
�mpenso�ion provisions of�he Labor Code,yo�m�st forth- Oven _Dryer _W.M._ ADDRESS
fh comply wilh Such provision5 or �his permit sFall be Top _FAU —W.H.—
emed revoked.- � CITY Tel.No. �
IICENSED CONTRACTORS DECIARATiON Hood _Fon _Othar_
Dtsp. —Room Air�Coad. — ��N�� 'I p Class
aeby affirm tFwt I am licensed under povisions of Choplar 9 ���1�ER O7�y'`�� � .
mmancing wiih SeUion 7000)of Division 3 of iha Busi�ess DISTRICT NO. PROCE BY
1 Profeuions Code,and my license is in full fwce and effe�y - Powe�Appara�us 8 La�ge Appliances �� . Yy
�y /J��� Size B Type HP,KW,KVA,or KVAR� �h�Q 0
mse Number r II lit.Closs��_ � � Up to 1 Ind. - FINAL A ./ . . V
� � . Over 1 to l0 1ntl. DA� `/�7/�`�' VALIDATION� �
� arotlor ,� Date p3 Ovar 10 to 50 Ind. - �
FINAL
, I om exemp�under Set. � Over 50 to 100�nc. BY �
��. B.SP.C.for this reason . �e��� y
Services,Swbd.,MCC 8 Ponelboords � . � � Z
�O1e' 0-Z00 Amp.Under 600 V
�� Signolu�e 201-1000 Amp.Undar 600 V .
Over 1000 Amp.or Over 600 V
�'Ezemption for Reg.NainL EIeU. - � � - �
SINGIE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One�&anch Circuit � �
�by offirm that I am exemp�from Ihe Conlraclor's license Addi!ionvl Sign Branch Circuils
�or the following reason(Section 7031.5,Business and � ��'L1 S Q S I1
ssions Code�: � . � � � I
Miu.Conduih 8 Conduclws - -" -- - #"�� � �'�2 - �
I,as owner oF the property,will do the work and the . �
struc�ure is nof intended or oHered for wle(Section -- aher(See Complete Fx Schedule)_ ► . _ .�.�:�4 Q 5 0
7044,Business'and Profassions Code). - .
� CONSTRUCTION LENDING AGENCY _ •.� •4 Q 5 0�
Sy affirm thoi there is a const�uction lending agancy for �2� 3�8 3
�rformance of ihe work for which this permit is issued PERMIT FEE � (Sub•To�el) �
1097.Civ.C.). . .
� PLAN CHECKING FEE � � � - � . , .
's Nome � � - .
PERMIT ISSUING FEE . �.
�'s Address� � - ' �
y Ihot I have read this applimtion and stole thol the - TOTAL FEE � -
informotion is correct.I ogree to comply wilh all County �
xes and S�ate laws�egulaiing Elecvical wiring,ond � �
�ihorize repre o�ives of fhis County to enter upon � � � � � �� ' �
• antionad rty for inspection urpos . SEE REVERSE FOR EXPLANATORY LANGUAGE
e of Permi Da�
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