HomeMy WebLinkAbout1744A (10) WORKER$'COMPENSATIONDECIARATION 76AbC3 10/81 APPLICATION FOR ELECTRICAL PERMIT y�
I herehy offirm that I have a ceHifimfe of consem ro self CE�806�
insure,or a certifica�e of Workers'Compensation Insurante, COUNT F LOS AIdGELES BU�LDING AND SAFETY ��
��tS�hRy tQ�of(Sec.3800,Lob .) u
i 1�t7•�y,A
O[y o. COmpo ` FOR APYUCANT TO FlLL IN J06 �
Cerlified copy is hereby f�rnished. New Residenrial Dld9s.&Pools EACH NO. FEE AD�RES :�
� Certified copy Is filed wiih the covmy bu��d�ng inspec- �g 2-Family.Sq.Ft. ; — 5 LOCALITY
tion de Iment. Mu��i-iamily Sq.Ff. — NEAREST
CRO55 5T.
Res�den�ial Swimming Pools OWNER OR
' DatB Applicani�O L��, FIRM NAME �
CERTIFICATE Of E%EMPTION FROM WORKERS' Outlets:Rec_lighl_Sw._ � N`°��� --7
COMPENSATION INSURANCE F�rsr 20 AD�RE55� ( '}
(Thi�s�clion n��d nof M compbf�d if}h�work involr�d by Tola�No. Additional CITY��v . Tel.No
�h�p.rmit ta fo.on•hundr.d dollars(t�o0)or I�as.) ttAN CHECK
I cerfify thm in the performance of the work for which ibis qppii�q�
permif is iswed,I shpll not employ any person in ony monner .
so as to become subject to the Workers'Compensation laws. Ligh�ing Fictures First 20 ADDRE55
Total Na. Additional
Date applicant CITY Tel.No.
f+�LICE TO APPLICANT: If, afler making this Certifimle of Fixed Appliances Not Over 1 HP PERMrt
� �ption, you should become subject fo the Workeri Ronge_Heoter_D.W._ APPLICAN7 [�
.�ipensviion provisions of�he Labor Code,you must for�h- Oven _Dryer �W.M.— ADDRESS �"
with comply with such provisions or this permit shall be Top _FAU —W.H.— � `
deemed revoked. . CITY Tel.No
IICENSED CONTRACTORS DECLARATION Hood _Fan _O�her_ S-L
Dis �Room Air Cond. _ UCENSE OR
I here6y affirm�hot 1 om licensed under provisions of Chapler 9 P' REG.NUMBER � Clas _
commencin with Seclion 7000 of Division 3 of the Business a•
� 9 � Power Apporoius 8 large Applionces DISTRICT NO. PROCES BY
and Professions Code,ond my license is in ful I force and effect. p
Size&Type HP,KW,KVA,or KVAR U
License Nomber � �`�Lic,Closs ` FINAL �
Up to 1 Ind.
Contractor���-�� Date Over 1 to 10 Ind. DATE �.r F VAUDATION � �
�3�O
Q Over 10 to 50 Incl. W
FINAL
I am ezempt under Sec Over 50 to 100 Inc. BY h p.'
8.8P.C.for this reason Over 100 �� Z
pa�e. Services,Swbd.,MCC 8 Panelboards , —
0-200 Amp.Under 600 V ='� 7 4.�4�
5gnature 201-1000 Amp.Under 5W V ��e e .'2
� Over 1000 Amp.or Over 60p V ���
Eaemp�ion for Reg.Mainl.EIecL � • � C l.f)f�
SINGLE FAMIIY Temp.Power Pole B Appuitenances
HOME OWNER-BUILDER DECIARATION � a • � G%,C;h'u
�� Sign with One Branth Circuit �
'by offirm Ihot I om ezempt from ihe Controctor's License Addilionol Sign Brpnch Circuits � . S
L. ,or Ihe following reason(Setlion 7031.5,Business ond � L.� 9—�
Professions Code): �
. ❑ I,as owner of the prope��y,wili do Ihe work ond Ihe Misc.Conduits 8 Conductors
shudure is not intended or offered for sola(SeUion Orher(See Compiere Fee Schedule)_ ,
70d4,6usiness and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm Ihoi ihere iz a construction lending agenty for
' the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec.3097,Civ.C.).
� PIAN CHECKtNG FEE �
Lender's Name
PERMIT ISSUING FEE � �C�
lender's Address
I certify thot I have read this applica�ion and state Ihat the TOTAI FEE l.�`
above information is correct.I ogree b mmply wiih all Counly ,
ordinances and Stale lows reguloting Electricol wiring,ond
here6y authorize represenlatives of ihis Counly to enler upon
the o6qve-me �oned p�operry to��nspection p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��,C��4 k'�2 �[���QI �
`Siqnarure of Perminee pote
... . � _ � . ..
. . .. . _..... ._. . ... ' ,-- .. • � . ,:.._ . .�. . :. 1 _...__ _ ILDER D..0 TI N
� � AFFROVFsLS � pATe. . �� O'v�1NER BU ° IARA O �
. ��SIGNA7URE�. . . - . . . . , �-
--��� � � �� - ' � '— � � � � � I here6y a?firm'tba!I em nxempr from ihe Controc�o%s
• �- TEM,P.POVlER PO.[. - -- "- - ' '
. _ � �� � . � licenso Lpw`,or the following reo:on (Scction T03L5.
� ---" --� �- - �- � - UNDERSLQBN/ORK � -.. , �• , fiuslnnxspndProfeszlonsCode):Anycityorcountywhich
-" ROJGN CONbUIT � . - �� � � � reqVlres c permit fo cnnstruU,aHeq fmprovd,�omollsh,
. .. ... . ._. _ ..,. . .
"/--� � �� or�epalr any sffucfure,prfor fo Ils issvance, also rc-
-- � �- - - �'� WIRING-` � � j�c,� , � � _ . qulreslhoapp!lconf/orsucApermitfoflleaslgnedsfale�
, - �� KIXTURES � � � - . . � mcnf�hcf he Is!lrensed pursuon�ro the proWsfons o(iho
�- ,- - - . Controc!or"s!![ensa Lhw(Chbpfer 9(commencing wflh
" ' � � _� fOV.'ER:.UTHOR2E� - � - -- �-� ' � -- � - � Sottion 7000)of Divlalon 1 ol,fhe Bosiness ond Profes� .
� � "'" �-- � - - sbns Codo)or tfiat ho Is exempt fhere/rom ond 1he basis
... _' _ .._._._ _.
U7ILINCO.NDiIFIE� . for the clfe6ed er.empiion. Any vlolctian ol Setfian .
' fINA: n ' C7 � ' � . 7G31.5 by any appfitonl lor o permlt subjocts the.oppl%-�
_._.__ __.._ .- - �C I+�ci on_1-ron( � car.f fo a dvll per,c[fy o�nol mo�e fhan i7ve hundred
_. . ._. . .- r;Q7E5 � � � � � doflars(SSOOJ.r . .- .
-� --�- ---' - � . . . . - '.. .. .❑I,os owner a;the proparry will do the wcrk.--�+d
� � - � . ihy struciu�o is not Inionded or oFfored for solc: �
��� � � _ . . _ . _ (Sec.7044,6vsinessond7rafesslonsCode:' 7fieCan..,c
� - ' tor i Licansolov+dces no�opply to an owner o�properly
" , . . � . , � , who buqds or�tmprovas lhoreon, ond who does such �
' -- � � � -- - " - �- " � � � - work htmsel/provfded fhot such improvemenls are not
�. - . � . . --� - -� - - - � � � Inrended ar o/forcd/or 4alc.1/,howeveF,Ihc huifding ar
. .. _.. . _... .. � .. . �.' '-: . '..
� � Improvemen)Is sold wifhln onc yevr ol compleflon,ihc
; � � ' . � ownervSutld^r wtl!have�he bbrden of provtng ihc�he did �
_ � � � � ` � rio�6ulld or lmprovc�or t6e purpoza of safc.)
�� � � � I am exampt under Soc. �
� � .- B E P.C.for this reason � . �
, . . ' ' , � -Date�- �
Owner
� . . � . .. . � � . . . �. . -.. ., . . .. . r . .
... . . . . ...__ '""
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