HomeMy WebLinkAbout1296A WORKERS'COMPENSA710N DECLARATION ��� ��,81 APPLICATION fOR ELECTRICAL PERMIT �
I hereby affirm thar I have a certificote of consent to self CE-80bG
inso�e,o�a ce�uficate af Wo�ke�s'Compensation Insurance, COUNTY Of l05 ANGELES BUILDING AND SAFETY
or o certifi 'copy lhereof(Sec.3800,Lob.C.)
P❑o�'ity N���ompony ��" � FOR APPLICAN7 TO FILL IN 10B
Certified copy is here6y furnished. New Residential Bidgs.8 P ql �CH NO. FEE �+D�RE55 /� .r
� Certified copy.is filed with rhe county building inspec- 1 8 2-Family,Sq.Ff.� S — E IOCAUTY � �
NEAREST
tion epa Iment. Muhi-family Sq.FI. CROSS ST.
//1//�i�-r�,4 Residenfiol Swimming Pools pWNER OR �
Date���Applicanr
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Ourlers:Rec_Light_Sw._ Mail
COMPENSATION INSURANCE ADORE55 O
tThis�scfion nead net b�aom Itlrd if�ha work Involvad b FirS�20
he parmi�ts for on�hundrod dolloFs{SI00}or I�ss.) Y Total No. Additional CITV � Tel.No. ?
I certify that in the performance of the work for which this A PNCCnH�K
pa�mit is issued,I shall not employ any person in ony monner
so as to become subject to the Workers'Compensmion Laws. ��ghting FixW�es Firs�20 ADDRES$
1""
Total No. Addilional CITY Tal.No.
' opplican� Fixed Applionces Not Over 1 HP PERMI7
NviICE TO APPUCANT: If, after making this Certificate of APP���� � �
Exemption, you should becoma subjed to the Workers' Range_Heater_D.W._
Compensation provisions of the lobor Code,you must forth- Oven _Dryer _W.M.� ADDRE55 �Oi /
ith comply wilh such provisions or this�permit shall be Top _PAU —W.H.—
deemed revoked. Hood _Fan _Other_ CITY �(f� Tel.!Jo
IICENSED CONTRACTORS DECLARA710N LICENSE OR
Disp. _Room Air Gond. — REG.NUMBER � Clos. /�
I hereby pffirm thol I am licensed under provisions of Chapter 9 � v }�',
(commencing with Section 7000)of Division 3 of ihe B�siness Power Apparalus 8 Large Appliancas D�STRICT NO. P OCESSED BY O
ond Professions Code, nd my license is in full force and effacl. `a U
/Y /� Size&Type HP,KW,KVA,or KVAR V" �
License N�mber lic Class__,��/ Up to 1 Incl. DA E� �i 0
�/J�`��'�� Dore_� Over I to 101nd. �?'l`r/G� VqUDAT10N �
Conlroctor Over 10 to SO Intl. W
FINAL a
❑ I om ezempt under Sec. Over 50 to 100 Inc. BY �, �
B.BP.C.for this reason Over 100 Z
Date: Services,Swbd.,MCC 8 Panel6oards� ,
0-200 Amp.Under 600 V
Signarure 201-1000 Amp.Under 600 V
OOver 1000 Amp.or Over 60p V
Exemption for Reg.Maint.Elect.
� SINGIE FAMIIY
HOME OWNER-BUIIDER DECLARATION Temp.Power Pole 8 Appurtenances
Sign with One Bronch Circuit
1 hereby affi�m�hot I om exempf from the Controctor's License Addiliona)Sign Branch Circuils �
Law for�he following reason(Setlion 7031.5, Business and .
Professions Code): �
❑ 1,as owner of the property,will do the work ond the Misc.Conduils&Condutfors
strocrure is noi intended or offered for sole(SeUion Other(See.Complete Fee Schedule)_ ►
7044,Business and Professions Code). '..� 2 9�i A
CONSTRUCTION LENDING AGENCY �1�r�4 � ��2
I hereby affirm thot there is a consiroction lending ogency for
Ihe performance of the work for which rhis permit is issued PERMIT PEE (Su6-To1al� � ��t °�G,�6
(Sea 3097,Civ.C.).
PLAN CHECKING FEE ° �� °E��E.G U�
Lendar's Name .
PERMIT ISSUING FEE O �'�2 5"H C�
lender's Address
I ceriify�hat I hove read this applimtion ond state that rhe TOTAL FEE
above informotion is correct.I agree to mmply with all County
ordinances ond State laws regulating Electricol wiring,ond �
hereby authorize represenlatives of Ihis Caunty ta enter upon
the ove-mention�roperty`�tion 6pur��� SEE REVERSE FOR EXPLANATORY LANGUAGE
O
Signoture of Permittes Dafe
i �, , � , + ! y : . . � "�� ;' �(��T � .�,��A
,.. � � -, .�: tafF��JVAlS DA7E - . . . .� . �I�'EdC�-BUI�DEt?Y�ECLARATIQN.
. . . � SiC`SAT;3RE � "` � �
� , ... , •� - r---- — �- 'sirm
.. - . � �I TEM?..pOW�i POLE. . . . �� 1 hereby o th�t I am exenpt°rom the ConPacto•'.s
- .. . - : L censo :aw tor the follaw ny ranznn (Sect�on 70J�.5,
� �JSV4ERSLAR WC<K ��—� Fusiness en�Pretesslons G'edeJ:Any city or count/wh`ch
� . RflUG'i CONDUII r.qu re o�'ief {}a eonst:ucf,offer-�I nnrovr.,[Yemolrsh.
.._.... —_._
....e__�___� ...._.�-_�{ �'�'-- � cr�reNair az�strvclure,p�lar to iN YssJamte, olso re�
WtR3RiG � . � qutrss tF.e a�nfimnt farsueh perm{�fq p)o o S�gned sfois�
� � - 4'fXfiURES ...��..`�µ_ ��� ��.' i . . meal thnt ha Ir 1tps,�seu pursuav.!te the provtsrons o/fhe
� � --{ Contrarto�s lies�ze tcs�r(Chapter 9(enmmrancing wlth
' . " �POv4�R�ALTH��CIY.Ea . . I ... .. Section TDG��csf Divis'ort�3 of thE:Business tl�d Ptoies-
-�--- �! -�--�—^' sions Cod�)or tho+hc�Is ezempt therelram cnd Yhe basis
�UTi�{TY CO.NOTIFSED ���_������������` ! ior thr; p,eagae� examatfan. Any violoV;on o! Seelfon
��"'""` c�`�"� . . . 7C3i.5 Ly cny oppllcU^t for a p�rmit subjects the appli-
FiNAL _� �����n�_����j _ J co,+P!a a civt!penp?ty of nct mcre t6aa fivo hund�ed
NOTES � . � � da!!ars($SuDj.: . �
- . ' . ' ��7.cs o�uner oP ina�seperty u,�ll do the work,-.�nd
� __ __.,...._.� _ � ..., 'he s':ruUu;c+is r.ot infendc;d cr offe!�d fcr�nle.
- �� . /Se:�.7Dd#,Susir=sscrndPrafessi�nsCbds: 7heContrao
__.. � — ' __.. _ � _._._T__ �_ �or's L�censr+law Coes not appfy tp nn owner of property
� . . � � . . who EsuNds ar'�r,rprave-. fhareon, cnd who dees sucFr
_ � �� _ � �.._� _.. .�_.__._._._ . v,.... wcrk h1ms�>f pravlc'�»d iha!snth-im�rovaments vre not
. � _ �� � -, � - � � ��� " � rnt,�nqud cr oftercd fnr safe.If,howova,r,the 6ullC/ng or
_'...__� �._____T�.__�.. ._�_�.._._.__�_.,v.____.______._.,...___.,_,._ � trnprcven�cr?ia�sotd wilt.=n one yev�of complefion,the
- � �ournar-tsu�Fc`ar w7�!hcve.fFn burden Ff proving fhot he drd
�..._. __.._ ..._�� " � 'neP�uFt��or Irnprove�!pr;ha rw�asa�of sale.J
. . � . . -... . . .
--- ._. __..._ . .._____,..�.._.._..__�. .. ... � _��.. _...� '��I am��xempt und�r Sec._�.�.�-._ �T�._.. ,
------._. �,.a - ....._..._._.....,�._._._ .r. . d� _ _._.. B u F.C.f�r ihis reas�n—,-----.- .
----- --_......_______.�_-- -.____._�._....._ .—. �_ aale
— __._____ ...�....� .__.�_._�_.__..._
�_.._._.. ...._ -- Owner.�_� ..��_�..__ ,_...— .
