HomeMy WebLinkAbout1075A (5) WORKERS��oMPENSAT,oNOE�LARAT�oN � �eAee3 �APPLICATION �FOR ELECTRICAL PERMIT � �
CE�OBG(2-80)
i hereby ati'vm tnat � have a cartificate ot consent to setf COUNTV OP LOS ANGELES ' BUILDING AND SAPETY
insme,or a certifiwte ot Wotkers'CompenseNon Insurance,or � � '
a certified copy thcreo((Sec.3800,Lab.C.)
I 5���_�� A,c FOR APPLICANT TO FILL IN JOB _ _ � .
PolicyNo.U'��Company p--�i•'" FACH NO. FEE ADORE5S i
Q , . . . New Reside�tiel Bldgs.&Pools _
Certifind copy is hereby furnished. 1&2-Family,Sq.Ft, S — S LOCALI7Y
M�Iti-tamiiy Sq.Ft. A
ertified copy is filed with the county building inspection CROSS 5T
de artment. Resfdentiel Swimming PoolS OWNER OR •
/ FIRM NAME
Date �� ^ ApO�icaat��T�'��6.�� Outlets:Rec..�Light_Sw._ MAIL
First 20 A�DRESS S� �
CER7IFICATE OF E?CEMPTION FROM WORKERS' Totat No. Additional Ci7V 7ei No. }
.COMPENSATION INSURANCG PLAnI CHECK �-
' � - ' APPLICANT ' �
Cfhis section need not be completed if the work involved Lighting Fixtures First 20 AODRESS U
by the permit is for one hundred dollees (5100)or IeseJ Total No. Additiona7 �
I certify that in ihe petformance of the work for which this CITY . Tsl No. F-
Fixed Appliances Not Over 1 HP � V
� Dermit is issued,1 shali not employ any person in any manner � P£RMIT � /
bo as[o bacome subject to the Workers'Compensation laws. Range_Heater_D.W._,_ qPP ICANT C=l�-�`� �- /5 eQ" pW„
N
Oven _Oryer_W,M._ ADDRESS� - Z
Date Applicant Top _FAU _W.H.� � ,� -�,�P,�,js� '
NoOd_Fan _Other_ CITY T��No.
NOTICE TO ANPLICANT:If,after making this Certificete of Disp._Room Air Cond,__ _ � u ENS O
Exemption, you should become subject to ihe Workers' � REG.NUMBER Cta.a C �
Compensation provisions of the Labor Code,you must forth- power Ap{iaratus&Large Appliaoces DISTRICT NO. �PHOCESSFFF,,,D BY
'. with comply with such provisions or thfs yermit shail be ', /O ��
deemed revoked. Size&7ype HP,KW,KVA,or KVAR
• Up to 1 Incl.
FINAL //
LICENSED CONTRACTORS DECLARATION Over t ta 101nci. oATE !�O aoZ��d VALIDATION
Ove�70 to 50 Incl.
I hereby effirm that 1 am licensed under pravisions ot Chapter Over 50 to 100 Inc. F INAL '
9 (commencing with Section 7D00)of�ivision 3 of the Busi• Over 100 8Y
ness and Yrofessions.Code,end my license is in fuil force and
effect. $erviCes .
License Number�3� Lic.Class 0-200 Amp.Unde�600 V .
201•1000 Amp.Under 600 V
� Contractor,��l Date�� �� Over 1000 Amp,or Over 600 V '
' HOME OA'NER•BUILDER DECLARATION Temp.Power Pale&Appurtenences r2� O Z 5 A �
[ hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit �,�•��
License Law for the foliowing rteson (Section 7031.5,Husi- Additional Sign Branch Circuits �f . '2
ness end Professions Code): I • • �9,� Q
Micc.Conduits&Conductors �
� I,us owner of the properly,will do ihe work and the Other(See Complete Fee Schedulel— • • _
structure is not intended or offered for sale (Setlion , �J.� O U
7044,Business and Professions code). : I 2 2� �S 1
CONSTRUCTfON LENDING AQENCY '
I hereby aftirm that [here is a construction tending ugency '
for the perFormance of the work for which this permit is pERMIT FEE (Sub-Totaq
issued(Sec.�097,Civ.CJ. -
Lender's Name PLAN CHECKING FEE (One�Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE' ' � �
I certify that 1 have read this�pplication and state thet the TOTAL FEE �
above infarmation is correct.[agree to comP�Y w'��h all County ,
� ordinances and State laws regulaHng EleUdcal wiAnR, end ,
� hereby aulhorize representatives of this Counly to enter upon . • � �
� the above-mentioned property for inxpection purpoaes. gEE�REVERSE FOR E%PLANATORY LANGUAGE '
�(i/—LyJ7�r� o?— ��'
' Signeture of Yermittee � Date � �
, � . , . . _ . � . OR'NGR-BUILD[R DECLARATION
� � I hcrc6y affirm Ihat 1 am e�empt fmm the Contracror's
����� �� � � iNSPecTOH's - License Latr or 2he tnllowing reason Sectior+ 7031.5.
' , . APPROVALS DATE .SIGNATVRE . ' ' r � ( .
. . , , , , � - Rusinrss ar�A�Profeasions Code/:�Any cify os courit}�
- - TEMP.PO�VE POLE � � � t�dl(CI! �equrres a pernrrt to carrsrrucl. alter, rmprove.
� � � � -- --- " uNOERSI.As�LvO�tF:� - derrrohih, ar repcir'm+��s7n�ctrve.prior 7o rrr issuance,
. - -- � eko reqr�rres the eppficartt for suclr pennrt ro file a
. -" - �- � - FtOUGHCON�UIT " � -�� � - � SiynCd staternerrl tGat he iS liCented ptrsumtt fo tlie
� � , prorisioms oJ r8e ContractorS Lrcenre Law/Clwprer 9
`. .- .. -�"..�_.. ' w�RtnG.; - � '� /rommencin,^-rcitli-�Section �OOOI OI Dii'i,siort 3 of�he
! _ .� ._ • ' Fix'ruPes �- � � . ' Uusiness m�d Projessiars CodeJ or t17at he is exempt-
. ,, . . . � � 1Gerejrom arrA the basir for the afleged exemprton.Any
- _. _. .. � PObvERau7HOFl12E� riola�ro��ofSection703l.Sbyanyapplrcmrtjorapernrtr
' - viiurv c0.No7iFl�o= � subjec7s tlee applicaru to a ciri!penalfy ojnor m,ore d�arr
.. - - � five Hund�cd dallers(SSOOJ.: � . . ' .
� ._ _ _ FiNnL � �'r.tch 4st ��oit� ' O 1,as n«�ner of tLc�proPcrt}�witl do thc��-ork,and
� � Pdo7E5 � � �, � , � � ,Nie structurc is not intended or offered fnr sale. . .,
- . � - � � . . � -� /Sec. 704�t, IJurinesr and Prnfeasions Code:. Tl:e Coi��
' .� . lrarta�'s J.icciirr Lcw.does.not apply fo mr owr+er of
, property rvha builds ar irnprOves tltereou.prtd�rAo doe.c
� �� , � . - � '3 . '. ' �� � s+ch �aork hinrsclf provrded Orct sucl+ lmprorfrncnfs
. ..�� , are nnt interrded or offereil far sale. /f, Gowe��er, tire
� � , � � � � ' - - - burld+n; or impro�•emcnt lr .rold x•it/ri�v o�re �•car oJ
, canpletron, tAe Ow+icr-b�eilder �vill lrm�e tlre 6urden
� " � � ' � ' ,. � . � , ' � . . , of pro��in�.tlrai he drd no� burld o�•improvc/'or tJre
_ , p�vpoxe nf salc.J .
. I am exempt under Sec. .
fS£c P.C.for this rcas6n
'�Date�
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