HomeMy WebLinkAbout1355A �.�� ___ - _ _
- - -- - -
i� � - �. rl�.������. �, .
WORKERS'COMPENSATION DECLARATION ���3 ,o,e, APPLICATION FOR ELECTRICAL PERMIT �
II hereby affirm that I have a certificate of consent�o seif CE-806C
ms��e,o�o cereticate of Workers'Compensation Insurance, COUNTY QF LOS ANGELES BUILDING AND SAFETY
I o�a certified copy�hereof(Sec.3800,Lab.C.) �
; Paolicy No. Compony FOR APPLICANT TO FlLL IF! JOB
� Cenified copy is hereby furnished. New Residentiol 81dqs.&Pools EACH N0. FEE ADDRE55 Z'– �- L.L'
! �Certified copy is filed with the munfy building inspeo- 1 8 2-Family,Sq.FI. f — $ IOCALITY a 2
lio de arf enf. Mulfi-4amily$q.FI. — 'NEAREST
J � ,�,�/ Residential5wimmingPools OWNEROR .
Daie_1��Applimnf L�
FIRM NAME
/ CER FICATE OF EXEMPTION FROM WORKE S' Outlets:Rec�Ligh��5w_ ����
� COMPENSATION WSURANCE ADDRESS
First 20
- (Thi�soction noad not b�complr»d�f Ih�work Inrolved by Totol No.� Additional CITY Tel.No.
the permit is for ona hundred dollan(5100)or loss.} PLqN CHECK
I rertify ihot in 1he parformance of the work ior which ihis APPLICANT
permit is issued,I shall nor employ any pa�son in any manner
so as to become su6ject to the Workers'Compensation laws. LigMing Fixtures First 20 ADDRE55 � . �
� To�al No.�_ Additional .
CITY Tel.No.
Date opplican� Fized Appliances Not Over 1 HP PERnnii ,/�
NOTICE TO APPLICANT: If; afte� making this Cer�ificate of APPLICANT {/�!
Exemption, you should become subject �o ihe Workers' Ronge_Heoter._D.W. _
Compensation provisions of the Labor Code,you must forth- Oven _Dryer —W.M._ ADDRESS p'�.��
wifh comply with 3uch provisions or this permit sholl be Top _FAU —W.H.—
deemed revoked. - Hood —Fan _Other_ CITY � L � � Tel.Np. �a
LICENSED CONTRACTORS D€CLARATION . LiCENSE OR �
I hereby affirm thot I om licensed under provisions ot Chopter 9 Disp. _Room Air Cond. — REG.NUMeER Closs. �
(commencing with Section 7000)of Division 3 af Ihe Business power Appawt�s&Large Appliances DISTRIQ NO. PROCESSED BY
and Professions Code,and my licanse is in full force and effect. /O �
' Size 8 Type HP,KW,KVA,or KVAR� �
License Number��ic.Class �� Up to 1 IncL FINAL � a � V
Over I to 10 Incl. DATE �,U� VALIDATION �
Contractor Data �
❑ Over 10 l0 50 Ind. FINAL ✓ ~
I am exempt under$et. Over SO to 100 Inc, BY u�"�i
B.&P.C.for Ihis reason Over 100 y
Services,Sw6d.,MCC 8 Panel6oards � � Z
/�� ` D� 0-200 Amp.Under 500 V
Sianature W✓� �W1lX/�--- 201 -1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over bpp V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole 8 App�rtenances L� `�5'`��
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit #�� • � • •2
I hereby affirm thot I om exempt from 1he ContraUor's License Additional Sign Bronch Circuits
law for ihe following reason(Section 7031.5, Business and �
Professions Code): � � • •G�,7 J�
� � Misc Conduits&Conductors � C I ,7 5`
I,as owner of the property,will do�he work and the • o o^
siructure is not iMended or offered for sale(Sedian Other(See Complete Fee Schedule)_
7044,Business and Professions Code). N - ��.� �_.�5
� CONSTRUCTION LENDING AGENCY
I hereby affirm fhat there is a mnsiruction lending agency for �
ihe performance of the work for which ihis permit is issued PERMIT FEE (Sub-Totol) �/
($ec.3097,Civ.C.�. .
PIAN CHECKING FEE - � .
Lender's Name
PERMIT ISSUING FEE . [0
Lender's Address
I certify ihat I hove read ihis applicotion and state ihat�he TOTAL FEE � �
above information is correct.I agree ro comply wi�h oll County
ordinonces and State lows reguloting Electricol wiring,and . �
� hereby authorize repr sentotives of this County lo enter upon
the abave-q enfione roperfy far inspecti n pur ses.
� �/ / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signarure o P iitee a1e �
"'! ' - , - - - --- .
�3�*ii� .1� " �' ! , � �C � Yr' :J� �i, 5, � `` ����-- _
� e � . e 6
ArPaoVALS on� � OWNER-BUILDER DECLARATION
Si NAT R
TEMP.POWER POLE � I heraby affirm Yhai I am exempt from the Contractor's
- License Law for fhe following reason (Section 703I.5,
UNO€RSLAB WORK � Business and Profssslons Code):Any city or caunty whlch
ROUGH CONDUIT - reqatres a permlT to can�iruct,alter,lrnprove,demofish,
or repctr any sfrutture,prlor to Its Issuance, also re-
WIRING .�� � qoires 1he appllmn}for such permlt lo Ilfe a s(gnod stafe-
� ment iha�he is hcensed pursuant to the provlslons oi tbe
FIXTURES ConTrocfOr's Lftsnse I.aw(Chopfer 9{tommencing witb
POWER AU7HORIZED Ssctlon 7000J of DJvfsfon 3 of Ihe Business and Proles-
slons Cods)or�hot he Is axempf iherafrom and the basis
� UTILIN CO.NOTIFIED � for fhe alleg�d exemptlan. Any violarlon of Saclion
, FINAL n 7031.5 by any applironT 1or a permii su6(ecfs 1he appli-
Gnfar ox �ronE con/To a clvlf penaffy of rto!more than flve hundred
� NOTES dolfars(b500).;
, ❑I,os ownar of The proparry will da Iha work,and
tha struciure Is not intanded or offered for sale.
� � - (Sx.7W1,Buslnsss andProfesstons Code: TheContrac-
tor's Licsnse Law doas not apply fo on owna of property
� � who butlds or Improves Ibareon, ard who does such
� work Ftmse!(provtded fhat sacb improvements are not
� . Intendad or offered lor sale:N,bcwever,1he bullding or
improvement!s so(d wifhin one year of compleiion,fhe
� � owner-bvl(der wtll have the 6urden of proving�haf he did
not bulld or Improve for fhe purpose of sole.)
I am exempt under Sec. ,
B&P.C.for This reason
Date
Owner