HomeMy WebLinkAbout1369AWORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a Certified Copy thereof (Sec 3800, Lob. C.)
Policy No. Company
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion deportment.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
-
COMPENSATION INSURANCE -
(This section need not be completed If the work Involved by
the permit 6 for one hundred do Ions ($100) or less.)
( f fortify that in the performance of the work for which this
`�¢e t ,s rssued, 1 shall not employ any person in any manner
avl s to become subjecl to the Workers' Compensation Laws.
Do" elPPlte454J�i.�vG 1
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect,
License Number a�lCLic. Class—��
ontractor
❑ I am exempt under Sec.
B.&P.C. for this reason
Date:
Signature
❑ Exemption for Reg. Main. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 hereby offirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ, C.).
Lender's No n. 2&"CU— "T
Lenders Addresr � c (�(i �"Tac'74s bi--
I. terrify that I have read this application and state that the
W 6la,at
CE -6 APPLICATION FOR ELECTRICAL PERMIT
CE-
. COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO PILL IN
JOB
ADDRESS �f..�Di) S
New Residential Bldgs. & Pools EACH
1& 2 -Family, q S Ft. $
NO. FEE
— S
LOCALITY
.d
454C <4
MultiSq. Ft.
Residential Swimming Pools
NEARESTfamily
CROSS $T.
nfNER �
FIR,41 NAMErC-
IL
ADORES$
%
Outlets: Rec Light__ Sw.`
Firs120_ J
Total No. Additional
CITY CA
o4 Tel. No.?/
PIAN CHECK'
APPLICANT "
ADDRESS -
LightingFixrures First 20
Too l No. - Additional
CITY
Tel. No.
Fixed Appliances Not Over 1 HP
Range_ Healer_D.W. _
PERMIT
APPLICANT
TG
ADDRESS /
40
IyzTop
1.'T-
JYZ
Oven _ Dryer — W.M.—
_ FAU _ W.H. —
Hood _ Fan _ Other_
CJ TY • r
Tel. No. 3
LICEN
REG, N MRER
'j - Class. /C9Power
Oisp. _Room Air Cond.
DISTRICT NO
PROCWED BY
Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
FINAL
DATE VALIDATION
Up to 1 Incl. -
Over 1 to 10 Ind.
Over 10 to 50 Incl.
FINAL
Over 50 to 100 Inc.-
BY
Over 100
Syriws-S-buL_AAGC-" oord
O 0 - 200 Amp. Under 600 V
J
,
_
201 - 1000 Amp. Under V�/�7�]
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
( a r°� ` C `
s s - :. 7 ` s
Additional Sign Branch Circuits
'
G2� I G—i G
Mist. Conduits & Conductors
-
-
Other (See Complete Fee Schedule)_
► "
PERMIT FEE (Sub.Total)
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
3LD, QIS
above information is correct. I agree to comply with all County
ordinances and Stare laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of rminee Dare
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