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HomeMy WebLinkAbout1745A WORKERS'COMPENSATION DECLARATION 76A6W �o.e� APPLICATION FOR ELECTRICAL PERMIT [� I hereby aifirm tha�I have a tertificote of consenf to self �E"� II insure,or a certificate of Workers'Compensation Insurance, COU F LOS ANGEL Bl11LDIPIG AND SAFETY 11 or4 c_elfifi��yqyyF}Gr�oE,(Sec.3800,lob.C. -""� (, �� -��p� �:���5 FOR ARLICANT TO Rll IN JOB ) .aq i•�o. Company Cerlified topy is hergby furnished. New Residen�ial Bldgs.8 Pools EACH NO. FEE A�DRE � �Certified copy�s filed wiih the caunty build�ng inspec- �8 2�Family,Sq.Ft. f = S 1 LOCALITY fio de finent. Multi-(amily Sq.FI. NEAREST Q �1 Residemial Swimming Poois � owNea Ort� Date Applimnt` �A�rr FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Ligh1_Sw._ � � pORE55 � COMPENSATION INSURANCE FirS1� (Thi�t�cflon nMd net b�compl�f�d ii th�work involr�d by Total No. Additionol CIT U���7 Tel.No th�p�rmil is for on�hundr�d doliers(f100)or bas.) FLAN CMECK I certi(y�hot in the performance o(the work for which ihis APPLIG4NT permil is issued,I sholl not employ any per5on in ony manner . so as to 6ecome subject to the Workers'Compensation Lows. Lighting Fixtures First 20 ADDRESS - Total No. Addltional CITY Tel.No. Da�e_ opplitanl Fixed Appliances Not Over 1 HP PERMIi �'CE TO APPLICANT: If, ofter making Ihis Certificote of AVPtICANT .iption, you shoold become subjeU to the Worked Ronge_Heater_�.W.— Compensation provisions of fhe Lobor Code,you must forth- Oven _Dryer _W.M.— ADDRE55 �� .wi�h comply with such provisions or this permit shall he Top �FAU —W.H.— � CITY �� Tel.N � -deemed revoked. Hood �Fon _Other_ LICENSED CONTRACTORS DECLARATION � LICENSE R � I.hareby affirm thot I om licensed under provisions of Chopter 9 Disp. _Room Air Cond. — REG.NUMBER Classe;�[� � (commencing with Section 70W)of Division 3 of Ihe Business DISTRICT NO. PROC D BY a Power Apporotus&Lorge Appliances .ond Professions Code,ond my license ie in full farce and eNect. O (' ���'�( �%'� Size 8 Type HP,KW,KVA,or KVAR� U License Number�S�.?S.C�lic.Class� Up to t Ind. FINAI �" � n1 -r� Over 1 lo 101nc1. DATE ����t��' VALIDATION U Conlraclor�v �, Date L Over lO fo SO lncl. FINAL � ❑ .I am e.ampt under Sec Over SO�0 100 Inc. gY � : � �h, �:� � B.BP.C.for this reason �Vef�� - , V Z Oate: � Services,Swbd.,MCC 8 Donelboa�ds , ► '�',�.�p f�� 0-Y(10 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V • . i � �;�7' D - Over 1000 Amp.or Over 6pp V Exemplion for Reg.MainL EIeU. � �,� 9-�;� SINGLE FAMILY Temp.Power Pole 8 Appurtenances � �. HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit f oy affirm thm I am exempr from rhe Contracror's license . Additional Si9n Branch Circui�s Lo..4or the iollowing reason(Section 7031.5,Business and Professions Code): . � ❑ I,as owner of the property,will do the work and the Misc.Cond�ih 8 Conductors � � strvcture is not iMended or offered for sale(Secrion Ofher(See Complete Fee Schedule)_ , .. 7044,Bus�ness and Proiessions Code). CONSTRUCTION LENDING AGENCY I hereby affirm Ihot Ihere is a tonstruction lending agency for the performonce of the work ior which this permit is issued PERMIT FEE �Sub-To�aIJ (Sec 3097,Civ.C.). � PLAN CHECKING FEE � lender's Nome I b � � PERMIT ISSUING FEE 1 lender's Address I � I certify�hat I have read thrs opplication and srore thot ihe TOTAL FEE � � , � obove in(ormo�ion is corred.I agree to comply with all County ordinances ond$tate lows regulating Elecfrical wiring,and . � � � hereby oulhorize represenlo7ives of�his County to enler upon �he obove-m tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � O Signature of Permiltee Date -. . , � . ...... ._.. .. __.__.. _ . . , _: - - - , . �� -9UILDER N . �. O'vVNER DECIARATlO f����� � �' ' � ACPROVALS DATF. . . --.SIGNATU�E- --_.,..' ._� . �. _.. .. . � �,__ ....._ . _ . ... _ _. ... �-'� �- � -- � �� -�� �-� �� � ... - � � � � ���" . I horeS effrm�ih6!1 om exem �from fhe Contrac�o•'x TEh',P.POWER PULE. . ---- -_ -.. . � . ,, .. Y P ; � ._ .__ .. . . .�� � ���. ' - � ' ' . Licensa Law for��ho fotlowing roo=on (SecUon 00.91�3. �- -�� UNDERSLAB V:02K �� ' - � - � . � � .._. _ . . .._._... _. _ .��- , � � � Euslno:scndP�a/ess7onsCode)rAnycllyorcountywb7ch. � � � roqvtres a pormN to consfruc�,alror,�lmprove,�demollsh, . ._._. __.. _ ______ FOUGH CO?1DV�T .. '. . . . . .. :.., ., . . . . . � � � - -oi repalr.ony s�rudvrc,�prlor to�ils dssuoncv,-also-re• -�--�- -�- - �—-� -' �� WIP.ING � -_, - f � � .� , . ' qulro�fhs opp!fmnt forsueh pormlt fo 1tle a sfgned sta�e- � ��- .-�, �� . .., �. ..�. . " ' �� . '' — -� �- � � mcnt lhof he ts lfcsnaed pursuoni to the prov(slans ollhe � _____ . '. . . • .-_�_.FIXTU�ES� =�- � �- � ' � - �.;Confractori Llcrosa Lvw(Chapfer 9,(commencfng�w71h � . __ .. ... _ _ _.. ' . � � ' � ' � �� .. POVlEF.FlUTNORIZED� - -� �� -� -- ' � - �� - ����� �� � Socfion 7000J o(Dlvisfon J ol fho Business and Profe:- - . � . , sl�ns Codo)or fhal bc!s axempt,fhero/rom ond fhe basis + UTIIIN CO.NOTIF�Ep ; . fw the alingod oxampf7on. Any�,v/olatlon o/Secl7on _......_. . � � � .�.. ..-�� FINAL �+ -�� --- �� - .- ."�..,. � ,.. .� •. '" � �7CJi.5 6y any applicanf(or a permlt subjocts the apAli- . _ _ _ _ __.. .. __ _ -�C�n�c�on �ron! , - � � cant fo a dvl!penelly o(no�more ihan flve hundred -� VOTES . ' . - �. '. '�. ' do/lars(SSPOJ.: ... . ___...._ .�.�_�.'.. ... ..._. __ . . ._. _. . . . . . . . . '.--._.. .. _.. �.... . , ._ � � , � � - '� � ��'' �I,os owner of iho property will da-�he wor4�^d � '� ' � the strucluro is not fniendod or oftored fo�sale.,,� • , . , , - ._ . � _. . . . , . �-(Sea 7C49,Ousinesi ond Proleestons Codo:� 76e Conrrac- ���.-� ' � -� " - � �� � � tor's LI.^anso Lvw dces nof apply to an ownar ol properly� _. _ .. __'. ' ._ . ., � ' '.r'�, ' � � � � • „ . . . . who ballds or'lmproves }Foreon, ond who docs such - �-- - -- � �'- � - - � � � -� -�� work hirirseff proLfdod thaf such 7mprovements are nor � , . . � ' ... • ..•- - .. .---. _.-.-. . '"`.. ... � - �. lnfen8adorof(erco'forsafo.If.fiowever.fhebutldingor - � '- �.......��..�.� -.... '.-: �..'•..:.��.'. � �_'.�..: .. . � � Improvement Is sold Wlthln one yoar ol tomplefion.ibe , . , � - � , � ownor-6vlld^r wlll hovc hhc 6urden af proving�Baf he did � � � � " no�b�i11d or(mprove lor,ihe.purpose pl sofe.) � � . I am exampt und=r Soc , ... . - _._ _ . . _ _ .. _ . _ . -_ 6&P.C.for this roason.� � . . . � i._--'----`_. '. �� ... ... ..- -- -- _ . _. _._ �" � � --. _ --� . ..... ... - _ .___.. __- �--.... _ , . � . . . ... .:. ! . __.. . �. �, ,..,_.� .,�.. .. Date � - - .. .._ __ . _ ��-�. . . � � Owner .. . . . .. - , .. . . . .. ., . . ._ ... ._ -�'�j . ' � .,. .. �.