HomeMy WebLinkAbout1634A (15)-'WORKERS'.COMPENSATIONDh:CI,ARATION *�
76A663 'APPLICATION FOR
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ELECTRICAL PERMIT {�..
CE 806G (280)
I hereby affirm that I have a certificate of consent to self
COUNTY OF LOS ANGELES
4 BUILDING AND SAFETY LI
insure, or a certificate of Workers' Compensation Insurance, or.:.'
-
-:- a certified copy thereof (Sec. 3800, Lab. C.) ,
FOR APPLICANT TO FILL IN
JOB n
Policy 005- ll fi9m Pany
f
New Residential Bldgs. & Pools
EACH
NO.
FEE
ADDRESS
Certified copy is hereby furnished. -
1 & 2-Family,Sq. Ft.
$
--
$
LOCALITY i`
Multi -family Sq. Ft.
—
NEAREST y}
CROSS ST3y
Certified copy is filed with the county building inspection
department. :.
Residential Swimming Pools
OWNER O
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Data Applicant +^{� t'7"ea4 `tea
Outlets: Rec.�Light_ Sw._
FIRM NAMEQY"Clstd
MAIL
First 20
ADDRESS_
CERTIFIC'.ATE OF EXEMPTION FROM WORKERS'
- Total No. Additional -
-
CITY -� Tel No.
>-
. COMPENSATION INSURANCE
PLAN CHECK
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0
APPLICANT
(This section need not be completed if the work involved
First
'• Lighting Fixtu r((e''s
ADDRESS
by the permit is for one hundred dollars (SI00) or less.)
o
� Additional `
O
T certify that in the performance of the work for which this
p
Total No. �
(
Fixed Appliances Not Over 7 HP j
CITY Tel No.
E-
LEI
permit is issued, T shall not employ any person in any manner
PERMIT ,At •�
so as to become subject to the Workers' Compensation Laws.
'� Range— Heater_ D.W. �
Oven Dryer _ W.M. _
APPLICANT h Q .�17£�s
ADDRESS. 12C5
a....
0-
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Centpensatinn provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3!of the
Busi-ness and Professions Code, and my license is in full force and
effect.
License Number / )Lrc. Claw- 41 f�
HOMI. OWNER -BUILDER DECLARATION
I berebv affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, BusE
ness and Professions Code):
I, as owner of. the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONS I'RUCI'ION LENDING AOF.NCY
I hereby affirm that there is a construction lending agency
,or the performance of the -work for which this permit is
issued (Sec. 3097. Civ. C.)
Lender's Name --
Lender's Address -
- I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the abov�e�-.✓m7 enti ed property for inspection
rpurposes. f
Signature ofj'ermittee Date
Top — FAU — W.H.._
Hood — Fan — Other_,.
Disp. —Room Air Cond—
Power Apparatus & Large Appliances
Size &.Type HP, KW, KVA, or KVA
Up to 1 Incl.
Over 1 to 10 Incl.
Over 10 to 50 Ind.
Over 50 to 100 Inc.
Over 100
Services
0-200 Amp:: Under 600 V
201-1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
,,.......,,..a! c.g.. Rra..^_h..
Misc. Conduits & Conductors
Other (See Complete Fee Schedule) -
PERMIT FEE (Sub -Total)
PLAN CHECKING FEE (One -Fourth Permit Fee)
PERMIT ISSUING FEE
TOTAL FEE
REVERSE FOR EXPLANATORY LANGUAGE
CITY- - Tel No. _-
LICEN E OR
REG. NUMBER ca7.+f - Class
!
DISTRICT NO.
PROCEED BY
FINAL
DATE j �i62-1
-
VALIDATION
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FINAL i•
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1pe10.90
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