HomeMy WebLinkAbout1741A (10) WORKERS'COMPENSATIONDECLARATION ��� ���81 . APPUCATION '�FOR ELECTRICAL PERMIT �
I hereby afiirm that I hovo o certi(icate of consent ro sel( CE-806G �
insure,or a certificate of Workers'Compensat�on Ins�rance, C NTY OF LO�A ELES BUILDING AND SAFETY
o�4er`�f� � ereof(Sec.3800,lab ) � �/1
P❑ol�icy�No. Compan FON APPLICANT TO FlLL IN JOB �_ �
Certified copy is hereby fumished. New Residen�ial 81dgs.8 Pools EACH � NO. ADDRES )
�Certified copy is f�ied with the county building inspec- 1 8 2-Fomily,Sq.F�. s — E LOCALITY
tio department. Multi-family Sq.Ft. — NEAREST
� � Residential Swimming Pools CRO55 ST.
Date Applicom���,d$� OwNER ai
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' ' � � � Mqil n
Outlets:Rec__Light_Sw._
COMPENSATION INSURANCE First 20 aDDRESS t�
(Tht�s�clion nNd nof b�eemplet�d N fF�werk Involv�d by To�a�No Additional CIT Tel.N
th�p�rmN b For on�huodr�d dollers(5700)or I��a.) PIAN CHECK
I ceni(y�hat in ihe performance oi the work ior which this � qppucnNT
permit is issued,I shoil nol employ ony person in ony manncr ,
so as to 6ecome subject to�he Workeri Campensation Laws. Lighting Fixtures Firsl 20 ADDRESS
To1al No. Additionol
Date aPPlimnl � CITY Tel.No.
� Fiaed App�ionces Noi Over 1 HP pEpnpii
'e'?ICE TO APPLICANT: If, afler making ihis Certificate of qPtti[qNi
iplion, you should become subjec� to the Workers' Range_Healer_D.W._
_..penzailon provisions of the Labor Code,yoo must forih- Oven _Dryer _W.M._ , ADDRESS
wilh comply with such provisions or Ihis permit sholl be Top —FAU —W.N:_
deemed revoked. Hood _Fon _Othei_ � CITY Tel.No
IICENSED CONTRACTORS OECLARATION IICENSE OR
I hereb affirm thot I am licensed unde� P Disp. _Room Air Cond. _ ; Clau .�t
y prOvision5 Of Cho ter 9 REG.NUMSER
(commencing wifh Section 7000)of Divis�on 3 of fhe Business '�, DISTRICT NO. ROCE55 D BY 0}.'
Power Apparofus 8 Large Appliontes
and Professions Code,and my license is in full force ond effect. . �l O
( ��Q��� �/� (��,�('� Size 8 Type HP,KW,KVA,or KVAR ' a�— U
license Number.�L�lia ClossJ= Up to 1 IncL FINAL �
n Over 1 io 10 Incl. DATE .7��'�r
Contractor�Y� Daie�� J (`� VAIIDATtON U
❑ Over 10 to 50 Ind. FINAL �� ��W
, I am ezempt under Sec. Over 50 10 100 Inc. 8Y �n-
Over 100 �
B.BP.C.for ihis reoson Z
Doie: Services,Swbd.,MCC&Panelboards � ,
0-200 Amp.Under 600 V
Signa�ure 201-I000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V r� �4 � �}
Exemption for Reg.Maint.Elecl. -
SINGLE FAMIIY Temp.Power Pole 8 Appurtenqntes �� @ �.� � ��
�^ HOME OWNER-BUILDER DECLARATION 5�9�w��h One Branch Circuit
} by affirm�hat I am exempt from the Contrac�or's License Add'nional Sign Branch Circuits I ` 1 G 1��'�:�
l .or�he following reason(Section 7031.5, Business and
Pwfessions Code�: • a � C,��.�'-Z'��' -
❑ I,as owner of the ro erf wil�do the wark and the M�sc.Condu�ts 8 Conductors
P P y� O�her See Com le�e Fee Schedule_ ' ► � �'� 9—�=�5
slruclure is not intended or offered for sole(Section ( P �
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY .
I hereby affirm thar there is a constr�crion lendin9 ogency for
Ihe perfarmonce of the work tor which Ihis permit is iss�ed pERMIT FEE (Sub-Totol)
�Sec 3097,Cir.C.). �,
PLAN CHECKING FEE . �
lender's Name
- PERMIT ISSUING FEE � r
Lender's Address
I certify thot I have read this applimtion and state thot�he TO7Al FEE �
above informat�on ii correcf.1 agree lo comply wiih oll County
� ordinances ond S�ote lows regulating Electrical wiring,and �.
hereby a��horize represen�atives af�his County to enter upon
�the above-me ' ned proper�y for inspeuion purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
��Q��,���Q�(7��r��L�
Signoture of Permittee ole '
. .._.. ._. . ... . . ._...._ Y . r . _ ' ;.' �, � ...�.' .. ' �.. . -� ;OWNEF•BUILDER DECLARATION - . .
; ' � A'PROVALS ....➢kTE .SIGNATURF . . . ... . � - .� . . �.. . . .... . -. . .. �
. � " � �� - - TEMP.�POLNER�PO�E , � -- � � � ' � � I hcreby affirm��ha'I om�oxompt from th�Contractor't
_ ._ _ . � � � . , , Litanso Low 4or��ne follawing reason (Section 701L5.
, --- �-�'" --- - - - UNDF.RSCkf,L'/ORK-- . � , . 8usiness ond Pro!esslons Code1:Any clty or couMy whlch,
- � ROUGH CONCUIT . � .._ � . . � . : � requlroi c porml}}o consiroct,al�cr,Improvq.demolish,
: � � � � � � �. - - or repoir any alrucfura,�pr;or to fla hsubnco,�ofso ra• �
' �- � � � ---- ������ �� WiRING ' � '�' ' � . . qutros fho appilcanf forsuch porml�fo fllo o sfgned sta�o-
� � � - � - mcnl ihaf hc is licr.nsed pvrsuon!to fhc provlilons oi the
_ . - _ � . _.. , FIXTLRES ' � • . Controctor's Lfcente lCw(Chapler 9(commendng wlfh
. . � � � . .. . PCflER AUTHO^nIZcD .- - � � � - ' - �- ' � Section 7G00)oi Dirltfon J of fhe 8usiness dndProles• �
- � � s/ons Codo)cr.fhaf ho Is exompl lherol�om and tFe bas/s-
. U7ILINCO.NOTIFiED ' � , /or Iho c/icpsd oxemptlon...Any vfofo�ion of-Secllon �
�ix(c�an J�onl � � ' - �7431.$6y any oppllcanf lor o permif su4jecfs Iho oppU��
_ FlNA; -�- . . ront to o eivtl penalty of not morv than flvo bundrod
� � NOiFS - � ��, - ' , daIlarz(3500).: �
._ . ... __. ._. . .. .. . . ._. _. .._ . . . �� . �� .
- � � � � - - . ��I,os owner oE the property wiC do��he work:--nd
� � ' � . Iho.'ruclure is nol infondod or offored for cole.
. _ � . , . _ _ � , _ . - (Sec.7044,Businoss onc�Fro/c3slons Code: The Co��..,c-
� ' � - _ _ � ��or i L(conse Low daes nor apply ro on owner o/property
� . � ! � ' , �who 6ullds or'Improvos lhoreon, ond who does svch �
�- -� -� ��-'------ . �- � -- � -"-�� �- - � �- -- � work hlmself proWdod fhot such�mprovemm}s are ncf
" � �- ���� � �'�- ��� ' �� ' i � . �- - � - � '" � � - �, Inlended ar nl/ored for sale.Jf,howeveq tho bullding or
-� ��-'� � � ��� � � - � �-� � � �� ���- � .� 7mpr�•emanl L•�:ofd wllhin one yeor ol tamplefion.Iho
' � . � � � owner-6�ilder w117 have tfie burdcn of proving fhaf he did
� ' ` � ' � � � ,nnt build or 7mpravo/or 16e:ovrpos^o/sa7e.).�.
- � � � � I am exempt under S�c. � - ,
� . . _ . �-. . . . . . . . ._ . . , �,. . . ... .
.. . . . _ . . 6 8 P.C.fcr this rcasor.
. .. . . . .. . �.� . . . . _ 6a1e- . . .._. . �
- O•:mer �.. ' .. � .