HomeMy WebLinkAbout1339A WORKERS'COMPENSATIONDECLARATION 78A683 APPLICATION FOR ELECTRICAL PERMIT � � �
CEbOBG(2�80)
1 hereby affirm that 1 have a certieicace ot consent t��xlr COUNTY OF LOS ANGEIES � BUILDING AND SAFETY �
, insure,or a certilicate of Workers'Compensefion Insurence,or c- ,� _ , ,
a certified c y t6ero f(�T800, ab.C.)�� � ✓ �
�L . FOR APPLI ANT TO FILL IN JOB
� � Policy N pany .
New Resideniiel Bldgs.&Poois EACH NO. FEE A�DRESS
� Certified copy is hereby furniched. 1&2•Family,5q.Ft. E — S LOCALI7v
. p�Certified�copy is filed with the county 6ulidine Inspection Multi-femily Sq,Ft. CROSS 3T �
r'de rtment. Residential Swimming Pools
g� pWNER OFl
/ �q �� f � � FIRM NAME �
. Dete:1_l�(_Applicant Outlets:Rec.�Li9ht 8 Sw.� ��� �2 MAIL �
� . First 20 AODAESS
CERTIf7CATE OF EXEMPTION FROM WORKERS' - Total No.�— ' Addi[ional C�Tv � 7•i
. COMPENSATIONINSURANCE � ' }
� P�Afv CNE ,� �'
(This aection need not be compieted if[he work involved APPUCANT �
by the permi[ is fm one hundred dollua (f10D)or lean.) �ight�ng Fixtures Pirst 20 qooRess � � .
Total No. 8 � Additional p
I certify that in the performance of the work for which thts CITY � Tsl No. U
ermit is ixued,i shJl not em lo an e son in an manner Fixed Appliances Not Over 1 HP
P P Y Y P� Y � PERMIT �
.so as to become subjzct to the Workers'Compensation Laws- Range_Heater D.W.� � APP ICAN7 a
- � Oven _bryer_W.M._ ADDRE�S y
Z
Date ADDlicant � ToP —FAU _W.H..� . —
� Hood_Fen LOther_ ) GTV Tel No �
. NOTICE TO AYPLICANT:If,after making this Cer[ificate of Diap, _Room Air Cond.� �� �f 3 a uC N E H � O
EzempHon, you should become subjecC to the Workers' . REG.NUMBER � Clne i
" Compensetion provisions o!the labor Code,you must forlh- power qpparatus&Large Appliances DIS7RICT NO. PRO�ESSED BY } /
with comply with suth provisions or this permil shall be gjZe&Type HP,KW,KVA,Or KVA .
deemed revoked. � . . � . � ��:�� /(�( ��
Up to 1 Incl.
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE � ��a np� . ALIOATION -
. Over 10 to 50 locl. ' .
1 hereby affirm that I am licensed under provisions of Chapter Ove�50 to 100 Ina. FINAL '
9 (commencing with Section 7000)of Diviston 3 ot the Busi- Over 700 BY .
ness and Professions.Code,and my license 1s in full force and - �
ef(ect. � 3ervices � '
• License Numb r Lic.Ciesa �^�� OQ00 Amp.Under 600 V
g 201-1000 Amp.Under 600 V
Contractor � Date ��j"�I Over 1000 Amp.or Over 600 V . � �
HOME OWNER•BUILDER DECLARqTION Temp.Power Pole&Appurteaances
1 hereby aff'irm that [ am exemDt from the Contractor$ Sign with One Branch Circuit . �
License Law for[he fotiowing reason(Section 7031.5, Busi- Additioael Sign BrenCh Circuits �1,y�9 F}
ness and Professions Code): � ' �
Miu.Cooduits&Conductors ��{"r• •'' •L
� I,as ownsr of the Droperty,will do the work and the Other ISee Complete Fee Schedulel— .� • •�8 7�
structure is not intended or offered for sale (Secdon
7044,Husiness and Pro(essions Code). . � _� �
CONSTRUCTION LGNDING AOENCY � �"' °�����
I hereby affirm that there is a construction lending ugency � � �
for the performance of[he work for which this permit Is - pERMIT FEE ISub�Totall 2O� �a'� `�y g'��
issued(Sec.3097,Civ.CJ. - � � �
Lender's Neme PLAN CHECKING FEE (One-Fourth Permit Feal ,
, Lender's Address pERMIT ISSUING FEE � � '
I tertify that 1 hove read this applicatian and state�hat the TOTAI FEE �„g 7
above informatlon is correct.I agree lo comply wifh all County �
ordinences and Stete laws regutaHnp Electricel wiring, and � � �
hereby authorize reprosentetives of ihis County to enter upon � � � .
the a6 ve-men' ed property tor inspection purpoaes. SEE'REVERSE 1'OR EXPLANATORY LANGUAGE
� -�Z� _,., �,� . . .
�/��'/
igna[ure of ermittee Date - �
. , , . , . _ 01YNEP.•FiUILDER DECLARATION
- , ..
`� . � � . 4. . I l:erebp affirm Ihat 1 am esempt tcom ILe Contractor's
F � �nf'FftOv�.LS � Dn7E !NCNAT�RE� . � - ' � ' Lic,en4c La��� for ihe fotlo���ing rcason/Section 7091.5.
i .
. - -. �;�Jlusiiiesr"and�Proj�stiaa CodrJ: Any ciry��w tou�rt}�
, Te^nP.�powe�ipOLE . -� ��-- � � � � , wGrch rrquires a penntt to rom.r�rt�ct, a!ter, improce,
'-' ����---�- - � �"� �UNo[FiSLAeV'iORY..�,+ ' ' � � ' � � �, delnOliSL,orrPpair�arl}'sfi'llcture,�prior'fo its��isPtipllee.
- -� � -- �� � , ob'o requires N:c app(ican�for tudi pennit to filr�a
. i- ... �...__. ." ROUGHCONDUIT"J.� . -.'';---� ' --'. . -. . � . ... � . � � ��� signed sfaterttcr�t tliaf Le is licensed p�irrt�anf to d�e
� �,... �
-- �- � �---�• '-�'-- wi�ttnlc � � - ' ' � provisirnts of�he Cort7ractor's I.icense Law (CLapter 9
`� � � . , .___. (rommertcir�� �rit)r,Se�iian�7000J oJ Dirisiorr 3 oJ fhe
� �. � �� -. . FiXTueCs ._-- _.. -`-�- -- � , �• � � � Business anct R�ofcrsions CodeJ or dicr he is e.rempt
,,� -�� , � .�� . - � �.. � ._...__. �..�.,.._ �•-� � _ ��'> � lperejrom m�d tl:r 6asis for Yhc alle%ed exemP�ron.An},
_.____ � ... ... _. �o�n�eftt,u'rHORizEo- -� riolarioirojSertion7091.5byanyapp(icaruforapcmri7
� _ .._.. __—..._ uTILITv co.n'oTIFlEo�'_ ' � - �. :,� . � � , stt6Jet7s rlte applrCaRt ro a ci�•if pe�inity oJno1 nrorP thnq
..... . . . , , . ' �. five H�mJrcd dollcrt/S SOOJ.: � � � �'
' _. . .--- Fir�n� . � _L'.:,t;1t. we �i 4wet � �� . . � ' � O 1,as�o�cncr of thc pzope�t}��dII do thc'�s�ork.and
� ' �" �ntoTes �' . i �_. � ' . , the structure is not intcnded or otfercd for s�le.
. - - � . - , , � �� - . , � /Sec. 7033, Brecirtess�and Profeasiats Code: Tf:c Con�
, ... . .� :�. " :.i: � .
. � � . , � . . , rracror's Liccusr Law•does nor nppl}� ro a�owner qj
. .- , .. �.�, , .... ' ,
. , . propen}�who buildr or irnpro�'es thereon,mtd xdto docs
� � � � . . ' ' -" �� ' � � � � � . sirch work hinuelf pronided d�ar ruch�irnprovemenrs
� , � - , . �. , �� are-not intended nr ofjered Jar�safe. If, however, d�e ;
. - . ' , - ... ._. . . buifdiirg or irnprorentent £c sold withnr one y�ear.oJ
� . .. compfe�ioir, 11�e owner�builder mill-!am•e �the burJen-
.. . . _ . .. . .._. . � - � . . . . . - . of ProrirZK.�that he did not 6uild:ar.rnrprore for the
. _. , , . . , purpome nf sa7e.J . ... . �
, , I am exempt under 5ec. .
� .. _ 1;&P.C.for this reason'
� � �, Date �
� . . . . ;�. _ _ � . , .. � � ' �� `,'�nwiier. . . . .. � � �
,I . . . � , _, .___ ;,_.. . _ . _ � . .. .. . � . . .. . .
� � ,. .. . _ _.._...... ._. . ._ . .� . . , .
. - . . :. ' . .._..I , . . .I+ . � . �� .