HomeMy WebLinkAbout1282A WORKERS'COMPENSA7'IONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT � �
_ - CE-806G 12801
i hereby aifrm that � have a certiticate ot consent to selt COUN7Y OF LOS ANGELES BUIIDING AND SAFETY
insure,or a cerlificate of Workers'Compensation Insurante,or � � .
. � a certified copy thereof(Sec.3800,Lab.CJ
� � - FOR APPUCANT TO FILL IN ,Ipg � / �
� �Yolicy No. Company EACH NO. FEE' ADOHESS J 7 C' � /�
' � New Residentiel Bldgs.&Pools �
� Certified copy is hereby fufnished. � 1&2-Femily,Sq.Ft. � — S LOCALITV
� Cerlified copy fs filed wilh the county building tnspection Mulci•femily$q.Ft, CROSS ST j
department. Residential Swimming Pools � OWNER OR �
)�� I/ fIRM NAME
Dete Applicant Outlets:Rec./..&Light�Sw.� V �� � qODFlE �
CERTIFICATE Of ERLMPTION FROM WORKF.RS' First 2
� � COMPENSATION INSURANCE � � Total No.� Additional CITY w T•1 No. }
PLAN C EC d
(This section need not be completed if the work involred P.PPLICANT �
by the permit is for one hundred dollus (SI00)ot lea�.) LightingFixtures F�rst20 qooHe3s
Additional �
� � Total No.� . � � q
� I certify that in the performance nf the work for wldch[his Fixed ApplienCes Not Over 1 HP CITY Tsl No. F_
, permit is fasued,1 ihell not employ y person in any manner � . PERMI7 W
so as to become subjuct to the W ers'Compensetion Laws. ftenge_Heater D.W._ qpp ICANT q,
�,{,�'/ Oven-_Dryer_W.M._ A�DHE85 LL LoQo j
Da[e��Appiit Top _FqU _W.H,_ ,
HOod_Fan _Other_ CI7Y �B�(t�-�x Tsl No. —�
NOTICE TO APPLICANT:If,atter making this Certificate of Diep. _Room Air Cond`_ LI NS /� �
Exemptiun, you should become subject to the N'orken' � REG.NUMBE � Cl�w C.�`/
Compensetion provisions of the Labor Code,you must forth- power Appatetu6&Large ApplienCes OISTRICT NO. PROC SSED BY
wi[h comply with such provisions�or this petmit shall be Size_&Type HP,KW,KVA,or KVA �/ �
deemed revoked. rI ,3� ac O ,
.ciy_ UP`o_1 Incl.
Over 1 to 10 Inel. DATE �
�LICENSED CONTRAC'IORS DECLARATION Over 10 to 50�ncl. VALIOATIOn7
I hereby affirm that I am licensed under provisions of Chapfer Over 50 to 100 Ina FINAL
9 (commencing with Section 7000)of D��isian 3 of the Bu�i- Over 100 � 8Y
� nss and Protessions Code,and my�icrnse Is in full force and
effect. �.��Q���� Services �
�� License Number�-J�.C2_LZ Lic.Class ��`�� �' 0-200 Amp.Uoder 600 V .
QQ 201•1000 Amp.Under B00 V
� Contracror � � � Dete �—O'"U/ Ove�1000 Amp.or Over 600 V -
HOME ON'NER•HUILDER DECLARA7ION . Temp.Power Pole&ApPurtenances � �� . . . ,
�1 hereby atFirm that 1 am exempt from ihe Contractor's Sign with One Branch Circuit - �
�. License Law for the following reason (Sectton 7031.5,Busi- Additional Siqn Branch Circuitc -
� ness and Professions Code): � �� �Q;��
� Miu.Conduits&Conducrors � �
� I, as owner ot the property,will do the work end the Other ISee Complete Fee Sebedule)— y � � ����
� structure is mt intended or offered for sale (Sectton � � �
, 7044,Business and Professions Code). . . � ` :%2� �
CONSTRUCTION LENDINC AUENCY �
. 1 hereby affirm that Ihere is a construction lending agency ' ,. • ° �z 2'� �� .
� for the performance of the work for which thls permit is pERMIT FEE (Su6-Totaq . ��
� issued(Sec.3097,Civ.C.). � O�'.-� `� ��
� Lender's Namr PLAN CHECKING FEE (One-Fourth Permit Feel '
Lender's Address PERMIT ISSUING fEE �
1 �1 certity that I have read this application and state thet the TOTAL FEE
above information is torrect.I ogree to compty with all County � . ` . �
otdinances and State laws regulating Electrical wiring, and \ � �
hereby authorize representatives of this County to rnte upon \
the abov entione roper for Ins eciion purp s�/ 'g�,��REVERSE FOR EAPLANATORV LANGUAGE .
Silneture of Per 'tee ate � _ '
�;
� „ _
r/ ' . . - 04YNGR-I3UILbLF DECLAR.4T10:�:�
- � I hereby'atfirm that.1 am c�cmpt[rom thc Contraclur's
� . ........ . ... . .. .
._._ ._ . .__.. . . .
� � l�va�tovnLs ; ❑arE iNSPflcron•s. � , — - Liccnsc I.atv for thc totlo«�ing rcason(Seuror= 7031.5,
`.._. . _. _: `, .. _:) .. � . . .
- - - StcNa7une . . � - . _ .&�ainesr and Professiont Code�: Any city ar roinuy
- - � -- � 7[�,�F.�ow�fi�POL[ - - � � � ��- � ' � �, � xdvirf� requires a permit ro constnut. alter, impruve,
- � --�-- - �- - � - � � � �" • dcmolish,o�rcpab cn}�srnrrnnc;prior�o rts issumrm,
- - -- -� -" � UlUDEFSLA6 PJORf:`.� � � - �.
- � ' - also requi�er d�c applicant for such pennit fo file a
. - --- �- � - ' �, Ftouct{cord_cU�T. - ��' ��/� � �� � . � � ' signed sta�emerst tpa7 /re ir lice�ued.P+�rs�rmrr to !hr
'�/��-3 �y'�z�-j _ prmrsions oJ tHe Carirractor's License Law.(CHapter 9
. - . . . ' t'����n���' � ' . . . , ... . (mr�rmcncing.ivith Secrion 7000J oj Diriiron 3 of-Urc
, ��
� -- � �'.'� ; Fi;7URe5 1 '. �,: .. . . . �`� '� ._�,.� . . Burinesx ar.d%rafessions CodeJ or tha� he is exempt
__ ...... _ . . . . �.
- � . ' � , . . . . - �,,. ' �h^rejrone anA tlic basis jor7he alfeKed ekernption:Ariy,
, � . . � ._ �Oti'�ett AUTaonYzeo - - .. � . . . ciolatiori oJ Sectinrt 7031.5 6}�anY'aPplirarst fora pennit
� � �� L7iU7v c0.N071REo � � , subjec7s fllc applrcan(fo a ciri!pe»afty of irot ntorr Uian
... .. . _ . . . - '. � � . �. � , - u�elurrtdreddollars/$SOOJ.: � -�, : `. ..
'._..- ... ---. . . ....FIPdAL_ - . -. �'�ttrlt a-�c �2a�tt �� � � . .. �' ! ❑1,as.o��•ncr of thc prope�ty ui11 do thc�vo�k,and
�'� i � ... ' nlores .. � .� . . � "' '� � .. � Sec. 7044,.Gusinesr m�d Pro etf�rcd forsalc. .
�_. _ . __._ . . _ .._ .-�... . .�. . � , ; . , �he slructure is not intended o�f�ssions Code: The Cun-
� , �. .' ' � - . � ' - . . .. rracro�tc I.icrnsc Law docs,not.apply ro mr oticner of
- , � . . property�rho buifdr pr improves tliercon,arid�eho docs
. � � � � ' � � . � � � � .such x•or1:��hirnrclf prV�'�ded fliat s�eck Im�riu�emeir�s
' . . . . . , . . . � are no:'i�irendcd a�r oJ(ered'jor sale. Ij, howerer. f1�e
� �� � - - � - - � - � bui.'ding or irnprovement is so7d wili+irs orte ycur,af
. . . , � coiripletion; the oivtterb:�ifder n�rlf l�m�e rFte burden
'"' . . "'� "' " -' ��-. . oJ proving 71m7 J�c�did�rrot build or inrpmrc jvr 7he
_ ^ .. . . .. , . �. . . p.�rpose nf salc.) , . . . . . . .
, I am exempt under Sec. .
,. . _ . -
- B&P.C.for diis rcason `
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