HomeMy WebLinkAbout0871A ERS COMPENSATIONOECLARATION 78A663 APPLtCAT10N F4R ELECTRICAL PERMIT {� �
- CE�SD6G 12-8D)
i hereby affirm that I have a certit��ate oe consent to sele COUNTY OF LOS ANGELES BUILDING ANp SAFETY ll
insure,or a certificate of Workers'Compensation Insurance,or � .
a certi ied copy thereqf(Sec�3800,Lab.C.) �
�I ������j �. , �l�� FOR APPLICANTTO FILL IN JOB�
Poticy o. Company _� � EACH NO. FEE ADDRESS
. New Residential Hldgs.&Pools �
� Certified copy is hereby furnished. 1&2-Family,5q.Ft. $ —' � LOCAUTY
Multi-familySq..Ft. — N A T '
, � Certified copy is tiled with the county building insPectian � Residential Swimming Pools' �.y CROSS ST � �.,.
department. . OWNER OR -
� � � . FIHM NAME
Date Applicant Outlets:Rec.^Light__Sw.._,_ qDD S
First 20
CEATIF[CAT£OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.(� �,
� COMPENSATIONINSURANCE � . ' a
. . PLAN CHECK � � . O
(This section nced not be compIeted if the�w�ork 111volved � - .�.PPLICANT V
by the petmit is fo[.one hundted d011a[e ($100)ax less.) Lighting Fixtures Fir9t 20 qDDRE55 - �
Additional
I certify that in the performance of the work�for which this Fixed ApPliances Not Over 1 HP � CITY � � Tel No. _. U
petmit is issued,I shall not employ any person in any manner � PERMIT w
so as to become�subject to the Workers'Compe�sation Laws. Range^Heater._D.W,_ APPLICANT a
- Oven _Dryer,_.W.M.� A�DRESS(�� �� Z
� Date Applicant Top,_FAU _W.H.._ . —
Hood�,Fan _Other_ CITY Tel No.
NOTICE TO APPL[CANT:If,after making this Certificate of Oisp. _Room Air Cond._ LICENSE OP �� � Ciass
Exemption, you should beoome subject to�the Workers' REG.NUMBER
. Compensation prwisions of the Labor Code,you must forth� power Apparatus&La�ge Appliances � DISTRICT NO. � PROCE �BY �
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA \O
deemed revoked. - '
� . Uptol lnCl. FINAL
Over 1 to 10 Incl, oaTE VALIDATION
�LICENSED CONTRACTORS DECLAAATION Over 10 to 50 Incl. 3�'�� �F"" �
1 hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL �,
S (commencing with Section?000)of Division 3 of the Busi- Over 100 . BY - �. .
ness and Piofessions.Code,and my license is in full force and '1'�-- � . . .
0ffect. - SerViceS - � � � � �
License Number,c�'�[L.Z� Lic.Class �..�� 0-200 Amp.Under 600 V � , , .. - . .
201-1000 Amp.Under 600 V . � .
Contracto�'��e�_� ���� Over 1000 Amp.or Over 600 V �� - . . .
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&ApPurtenances , � � � � . � .
1 hereby affirm that I am exempt from She Contrac[or's Sign with One BranCh�CirCuit � � .
License Law for the following reason (Section 7031.5, Busi- �Additional Slgn Branch Circuits �
. ness and Professions Code): � . � � r�f�,'� � � I
�� Misa Conduits&Conductors `
� i, as owner of the property,will do the work and the pther(See Complete Fee Schedulel— �!o • c�s •?
atructure is not intended or offered for sale (Section . �
7044,Business and Professions Code). - � - �Z
CONSTRUCTION LF.NDING AQENCY . I ' 'R'S� �
! hereby affirm that there is a construction lending agency - 6 -,�, s
for the performance of the work for which this permft is pERMIT FEE lSub-Totall . . �� y���r�L
issued(Sec.3097,Civ.CJ. �
LendeNs Name � PLAN CHECKING FEE (One-Fourth Permit Fee1 � . - � � [.�)L—��
Lender's Address PERMIT ISSUING FEE � � '
[certify thaT t have read this application and state that the TOTAL FEE ' �� .
above information is correct.i agree to comply with all County .
ordinances and State laws regulating ElectNcal wiNng, and � . ,
hereby authorize representaHves of this County to enter upon � �
the above-mentioned property for inspection purposns. SEE'REVERSE FOR E%YLANATORY LANGUAGE � �
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