HomeMy WebLinkAbout1368A WORKERS'COMPENSATION DECLARATION 76A653 i0/81 APPLICATION �FOR ELECTRICAL PERMIT �
I hereby pffirm thal I have a certifimte of consent�o self CE-806G
insvre,o�a certificate of Workers'Compensaiion Insurance, �DUNTY OF lOS ANGELES BUILDIN('i AND SAFETY
or a certi�ied copy thereof�Sec.3800,Lab.C.)
P�o�licy NaC25859571�ompo�y I�A FOR APPIICANT TO FILI IN ��g
Certified copy is hereby fumished. New Residenfial Bldgs.&Pools EACH NO. FEE A RE55
� Geitified copy is filed with the county building inspec- 1 8 Y-Femily,Sq.Ft. 74fl�i. s —' � � UTY
tion depar�ment. Multi-fpmily Sq.Ff, NEA
CRO55
�� Residentiol Swimming Pools OWNER OR
Date��_Applicar{E FIRMNAME E1ItdEII Ci
CERTIFICATE OF EXEMPTION fROM WORKERS' OuHefs:Rec�Light_Sw.� MAII
COMPENSATION INSURANCE ADDRE55
Firs1 ZO
(Th(s section need not be eomplNod if 1he work Involrrd by 7otal No. Additional ��T� COV�IIS �8. Tel.No. g(7-4541
ehe parmil Is For one hundnd dollon(5100)or(ess.) 7LAN CHECK
I certify thol in the parformance of the work for which this APPLICANT
permit is iss�ed,�sholl not employ�ony person in any manner
� so as�o become subjeO to the Workers'Compe�sation Laws. Lighting Fixtures Firs�20 ADDR€SS
�
Total No. Additional CITY Tel.No.
� Applicant Fixed A liances Nof Over I HP
t.._.wCE TO AFPLICANT: If, after making�his Cartifica�e of PP AP MI�NT �� ��
c T McGee Electric
Ezemption, you should become subject to the Workers' Range_Heater_D.W._ � -
Compensofion provisions of ihe Lobor Code,you mus�Forth- 'Oven _Dryer _W.M._ ADORES�_n l:c
wi7h comply with such provisions or this permit shall be Top _FAU —W.H:—
. deemed revoked. Hood _Fan �Oiher_ CITY Tel.No. �, 1
UCENSED CONTRACTORS OECLARATION UCENSE OR
Disp. _Room Air Cond. — REG.NUMBER 490083 ClossO-1�
I hereby offirm thot l am licensed under provisions of Chopter 9 a
(commencing with Section 7000)of Division 3 of�he Business pawer Apparafus&Large Appliances DISTRICT NO. �v PROCESSED BY U
ond Professions Coda,and my license is in full farce and effect.
Size 8 Type HP,KW,KVA,or KVAR�
490083 C-10 �
license Number Lic.Closs Up to 1 Incl. FINAL ! 0
Over I to 101ncL �A� r�f� �� VALIDATION ~
8/20/86 v
Contractor Electrical Dote Over 10 l0 50 Incl. FINAL a
❑ I am ezempt under Sec Over 50 to 1001rtc BY 9�1��/��Zryr� �
B.RP.C.for this reoson Over 100 j� �j z .
Date: Services,Swbd.,MCC&Panelboards ►
0-200 Amp.Under 600 V
$ignoture 201-1000 Amp.Under 600 V
❑ Ove�1000 Amp.or Over 600 V �.� 3�8 A
Exemption for Reg.Mainr.Elect.
� SINGLE FAMILV Temp.Power Pola&Apportenonces #'• o • e e 2
HOME OWNER-BUILDER DECLARATION Sig�„„irh One Branch Circuit 1 0�w 6 6 8 6
I hereby offirm ihat I om exempt from Ihe CoNractoi s License Additianal Sign Bronch Circuils
Law for the following reason(Section 7031.5, 8usiness and m ,.6�p�`
Professions Code):
� Misc.Conduiis&Condocfors
I,as owner of the property,will do the work and the ��.L�"B b
strvcture is noi iMended or offered for sole(Section Other(See Comple�e Fee Schedule�_ ,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that lhere is o mnstruction lending ogenty for
the performance of ihe work for whith thi5 permit is issued PERMIT FEE (Sub-To1ol) 56. F3
(Sec.3097,Civ.C.).
PIAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �.0. O
lender's Address
I certi4y that 1 hove reod ihis applicolion and stote�hat ihe TOTAL FEE 66.$6
above informotion is correct I pgree to comply with oll County
ordinances and State laws ragulafing E4eciricol wiring,and �
hereby authorize representatives of this Counly to enter opon
�the a6 ve-mentione property for insped�on pu�poses. SEE REVERSE iOR E7(PLANATORY LANGUAGE
� � 8/20/86
$ignature of Permittee Date
�.� �+ , � �, � . � � ! fC � ►i",iF� , .�.�A
� -- ' � .'.bWN[R-BUILDER DECLARATIOI+i��
AP�-�OVa!5 DATE _5_C4"�h.� . .. �� .
�1�� � � Ef+,R.FCY @R FOIE. � �� � - I hereby afFirm�hat I cm exermpt from fhe Confractorb
� , -- L cense ta £or the fnllowmg reason (Soction �03L5,
� l,��Ea,!.A� �h0�'X � � B Inesi ortd Professlons Code) Any city or courtTy whlch.
��� -��y raqvL-as a permli fo cons}rucf,pJfer,improve•demolisF.
2c3U tGON �i y � :�or�r9p�r-any�structure, prtor to iis�is9tipAie, olso re-
WIR'�_____�______-�/..�._�.�..7I��''��'''t`� i qufres the cpplicant for sUzh permtt ro flfe a slgned sfate-
. '�'�"""`-T-` t"'-T"`.`"'"""� ( � . ment�hat tie 7s ltrensed p�rsuanl ia the provfslons of tha
._ - ' . ��-F�.t'Tl�({#�4` � �
Contractor's Lkertse Law(Chapter 9(commanc7ng wlth
. �,_ ��._____._�_' _ Secticn 7QC6
� � � "F'OINER A.1TFdCRIZ�6 )of Dfv7stan 7 of tho 9usfness cnd Profss-
�- -- --~=____� slons Cadaj ar dhoi he!s exempt therefrom and fhe basis
UTI!{TY Cp,N�TIFlED ��� . !or tt;e alfege� exemption. Any violaiion of Seonon
c� 703I.5 6y any ap�pltcani ior a psrmit sub�ecfs the opph�
FlPdA:_ .�_ _��.j�,r or.:t�ronl corst ta a Uvfi penoliy o(not more}hon flvo bunc/;ed
hyTES � do/Iars(SSCQ].:
� , . . �i,as awnar of the property wilt do the wort�, _.�d
�� �� � � __,.' _ Ihe strutlure is not intended or offered for sale.
. . � (Sae.7044,Buxness ondProfessaons Code: The Controe-
______ ___ ._ . __ _ for's ticc�rssa lcw does noi appiy to an owner of proparty .
� - , ,,_ . wFo 6uiids ar'Impravas fhereon, and who does such �
-� � � � n�� �- � work hJmself�rOv�c�zrd that s�ch Improvements are nef
.__ _ ...._ __._ _—.�. _w. _
� - � � � , Intendc.d Or affered fur Sale.1/,howcvar,ihe 6uf(ding or
______ _„_, _.._ _ �mprovemenf is s�fd wifhin one year oi comp/e��on,ihe
, � awnar-bulldsr w71f have tha burdsn of prov/n,q that he did
� ��.�»� � fisrs¢}6u71d or lmprove for the,putpose of sola.J
�. _._ _.._��.._ � �-I am e�semot under Sec ,
w__� _�.M..�....__-- ---- --_.� _. .&E�P,C.for this raason�. �
�---_.-----.....-`----_�.__._.-----�._..._.�---.___---- �
_.__ - -pate
—.. _ � __.......__�__.. __ �
OWner _� _