HomeMy WebLinkAbout1806A IVORKERS'COMPENSATIONDECLARATION �BA883 APPLICATION FOR ELECTRICAL PERMIT {�
� CE�806G 1Y�801
I hereby affirm tnet 1 ha�e a certiticate of conaent to salt COUNTV OF LOS ANGEIES BUILDING ANp SAFETV LI
, inRure,or e certi£cate of Workers'Compensafion Insurence,or
a certified copy thereof(Sec.3800.Lab.C.)
� FOR APPLICANT TO FILL IN JOB
� Policy No. Company New ResidEntiai Bldqs.&Poois EAGH NO. FEE ADDpE65 Y Y1!
� Certified coQy is here6y furnished. 1&2•Famity,Sq.Ft. $ — E LOCAUTV � �� ('�1�'�
i � Cettified copy is filed wi[h[he county buiiding inspec�ion Multi•family Sq.Ft. CROSS ST Q /�f� • _
departmenL Reaidentiel$wimminQPo�� w OWNEFlOR �Fa�,so � . i�s� �
i I�f FIRM NAME
Date Applicant Oudets:Rea_Light_Sw._ qDDRE55 �1'Y1 t°
First 20
CERTIFICATE OF EREMPTION FROM WDRKERS' Total No. � Additional C�TY �� �7ai No. ?_�/5/d
COMPENSATION INSURANCE
PLAN CHECK d
� APPLICANT O
. CI'his section need not be completed ii the work invoived Lighting Finturas Firat 20 ADDFlESS �
hy the pe�nit ia for oae hundred dollua (5100)or leu.) qdditional � �
Total No.
� 1 certify that in the performance of ihe work for which this GTY Tsl No. �
Fixed Appliences Not Over 1 HP V
� permit is iasued,1 shall nnt empioy any pereon in any manner PERMIT
so as to become subject to the Workrr5�Compensalion Laws. Range_Heeter D.W._ qPPLICANT �'�t'r 1'� a
� � Oven _Dryer„_W.M._ ApOPESS N
� Dete Applicant Top _FAU _W.H._ Z
. HoOd_Fan _OthBr� CITV Tel No.
NOTICE TO ANPUCANT:If,after maki�g thls Certificate of DisP� _Room Air Cond� LICENS R .
' Gxemption, you shoald become subject to the Workets' REG.NUMBER duf
CompansaHon provisions of the Labor Code,you must for[h- Power Apparetus&Large Appliances OISTRICT NO. PROC SSED BY
with comply with such provisions or this permH ahall be Size&Type HP,KW,KVA,or KVAR � /1
deemed revoAed. � � p�
, Up t01 I�tl. FINAL �
' OVef'I tO101�tl. DATE p cJ VALIDATION �
LICENSED CONTRACTORS pECLARATION Over 10 to 50 Incl. �r�O�a
1 hereby atfirm that I em ticensed under provisions of Chap�er OVe�50 to 100�nc. BY'e'L , . . .
9 (cammenCing with Section 7000)of pivision 3 of tl�e Busf- ���pp
neas and Yrofessiom.Code,and my license Is in full force and
effect. . ServiCes '
Litense Number Lia Class 0�200 Amp.Under 600 V ,
201-1000 Amp.Under 600 V
� Contractor Dnte Over 1000 Amp.or Over 600 V . •
HOME OWNER-BUILDER DECLARATION TemP.Power Pole&Appurtenances � �
� I hereby affirm that I am ezempt from the Contractor's S�gn with One eranch Circuit � _� �C�F.
Licens0 Law for the foilowing reason (Section 7031.5,Busi• Additioael S�gn Branch Ci�euit5 �
.• neasand Professions Code): � i.�°'• • '�•� ,
Misc.Conduits&Co�uctots
�1,as owner of fhe property,wiil do the work and the Other(See Complete Fee Schedulel—
�\structure is not intended or oflered for seie (^xction � ��+G s���
, . 7044,Busiaess and Professions Code).
CONSTRUCTION 6EN�ING A�ENCY
1 hereby nffirm that Ihere is a construction lending agency � � ^�- (`�
for the performance oP the work for which�this peimit is pERMIT FEE (Sub•Total) � �Q.C']—?� �
� isbued(Sec.3097,Civ.C.). /
� Lender's Name PLAN CHECKING PEE (One-Fourth Pormit Feel �/J����/
Lender's Address �f /
PERMIT ISSUING FEE . - �j Q�,�.��K/
a � �a��A-�,� �t-
I certify that I have read this applica[ion end state[hat the TOTAL FEE �
above informadon(s correct.1 aYree to comD�Y�'��h all Coimty
ordinanees and State lews regulating Electrieel widne,and � � ���
hereby authorize representatives of this County ta enter upon ' -
the above-menNoned operty for 1�pecNon purpoaea. � SEE'REVERSE FOR EXPLANATORY LANCUAGE
�C - � _ ��,�/ .
' Si ature of Permit ae / ) � llate ' •
��
T•��'7 ——
� 014'NGR-BUiLDER DECLARATIG\
� 1 hcreby afCrm tha[I am escmpt from thc Contractor's
APPROV.ALS DATe iNsaecro�t's � Li�rnse La�r for tl�e following reason(Section 7031.5,
. , , _ sicNnTu�te . Rusi�tess mrd Projessioric CodeJ: Any city o� counry�
i.-- , - - . . � TCMP.PONiER POLE � � . N•Iiicii requires a penr�if ro canslrsrcl, alfer, irnp�o�•e,
' ��- ' � - - uN�[as�aa v�oRK . . ' �� denrolialr,or reperr an��smrtture,prior tn i7r lrruance,
� . . . � . . also requires nc� appficmrt jor such pernti[ ro file a
- . . FlOUGH coNouiT - • -- . .signed statement�that lie is licensed pursuert� to thc
' . , - - � pro��irions of tAe Caetractor's Lice�ue Law(Cf;a➢ter 9
. � ` . .. . . WiRiN� � , _ (rwrvnencng rvith Sec�in�i i00D1 of Dirision 3.of tl�e
_ � � PiKTUfiES � . � . � . (lusir�ess mrd Projessions CoAeJ or thar lre is exempr
� . ._ _ . dierefrorn and tlie 6a.ris for Ute nlleged cxemptiai.Any
. . � . . POVlER AUTHORIZED ciofo(iw�af Secfro�r�7031.5 b}�mrp npp(icant foraPemrif
unLi7v eo.NoriFien� � � � subjects die appficmi�to a ci�•i!penalfy oj not more t1�an
• � -. . - � -- . fire lrurrdred do!lars/$i00J.: ' -� � ' ��
. _ . .. FiNA� ' �'r�ch W= �Zan.� ❑1,as o�cncr of ilic property��ill do ihe���ork,and
� - � . � the structure is not iNended or offemd for 5ale.
' . NOTES '� � � . � � -� ' (Sec. 70-14, 6usir�ess nnd Profescinns Cade: Tlie Con•
� . • � " � � �ractor's f.icense Law daea�not appfy to aa oKmer,of
, propert)��who bui:ds or imprm�es Hvereon,und w7ro doea
' � � ' " � such x�orA himsclj prorided Nral sucli improrernears
, . are no� iivended or oJfered fur sale, lJ, l�owever,�tlre
- ' building nr improrcenent is sold x�ftlii�t oree��car of
cornpletiar,` ihe ownerLuilder +vi(1 haoe die burden
� � � � � � - ' � �. • - oj psovir�g timf !re did not build or improve Jor Uie
. . . . purpose of sale.) , �
l am exempt nnder Sec. ,
. I�&P.C.(oT this rcason
Dare
O�rner
' �
