HomeMy WebLinkAbout1619A (9) WORKERS'COMPENSATIONDECLARATION ✓ 1 76A863 ,o,B, �APPLICATION FOR ELECTRICAL PERMIT f�t
� I hereby aftirm that I have a cerlificate of consent to sell insure, �E-eOeG L 1
or a certiticate ot workers'Compensation Insurance.or a certitied COUNTY OF LOS ANGELES �S-tD ��7� BUILDING AND SAFETY LJ
copy lhereof(Sec.3800.La6.C.� w'w'�. i r�
PoliCy Na�������^+mpany -�„�,/r„� FOR APPLICANT TO FILL IN' ' JOB r n
❑ ,Certifietl copy is hereby furnished. , New Residential Blags.&Pools EACH NO. FEE ADoaESS '`_ /� a{f i F�.
1 8 2-Famity,Sq.Ft. S — S LOCALITY �
��Certified copy is tiled�wilh the county buiWing inspeClion _
� �department. � Multi-family Sq.Ft. NEnaEST
Dale�y f ��/`�"�i�,�,4 Residential Swimming Pools . eown�ea oR � S
Applicant�_C{^
- . FIRM NAME Ga
CERTIFICATE OF ExEMPTION FROM WORKERS' Outlets:Rec—LigM_Sw.— MAIL
� COMPENSATION INSUFANCE � n�DRESS p
�This nec'ion nead not be compleled H tAe work i�volved by!he First 20
permit le br oae hundred tlollers(5100)a less.) Total No. Additional CITY Te�.No. � lG
I certily that in the performznce of the work for which ihis permit PU�N CHECK
is Issued,I shall not employ any person in arry manner 5o as to APPLICAM
hecome subject to Ihe Workers'Compensation Laws.. . . LigMing Fiztures First 20 A�DRESS ,
� . � Total No. �ditional . CITY � Tel.No.
�ate Applicant Fizetl Appliances Not Over 1 HP pERMir
� NOTICE TO APPLICANT: If, afler making this Certificate of ppf�ICANT (ri�
Exemption,you should become subject to the Nlorkers'Compensation Range_Heater_ �.W. _
pravisions of the Labor Code,you mus[foAhwith eompty with such Oven_Dryer_ W.M._ ADDRESS y
provisions or this permit shall 6e tleemed rewked. Top —FAU _ W.H._
LICENSED CONTFiACTORS�ECLARATION Hood_Fan _ Olher_ CRY 7eI.No. .r`f/
I hereby affirm that I am liceneed under provisions oF Chapter 9 Disp. — Room Air Cond. _ uceNSE OR - 'Class.
�(commencing v�ilh Section 7000)of Division 3 of the Business and R[G.NUMBER O ��
Professions Code,and my license is in iNl(orce and eHect. , pawer Apparatus 8 Large Appliances _. OISTRICT NO. GFOCESSEO BV
Size 8 Type HP,K1N,KVA,or KVAR � �� �
L�ense Number������ Lia pass G��V � - ' - V
UP to 1 Incl. plA EL� �
. �� ���g Over t to 101nc1. VALIDATION
Cantmctor �-�/ �Dale �� pver 10 to 50 IncL U
❑ FINAL
I am exempt unCer Sec. Over 50 to 100 Inc. gy �
� 8.8P.C.tor this reason Over 100 �
_ - Services.Swbd.,MCC 8 PanelboaMs - , �� r'.1,6 t.9 2 y
Da[e: � 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Undcr 600V - ' - � o .2'r��5�
Over 1000 Amp,or Over 600 V • at L c p�
� Exemption for Reg.Maint.Elect � - � G� I L g Y �
SINGLE FAMILV Temp.Power Poie&Appurtenances �
HOME OWNER-BUILDER DECLARATION Sign with Onc 8ranch Circuit .
I hereby alfirm that I am exempt trom the Contractor's License l.aw Additionol Sign Branoh Circuits
for the followiny reoson�Section 7031.5,Business and Professions � - � � -
Codc):
❑ I,os owner of the property,will do the work and the structure Misa Condui[s 8 ConCudors � � - �
is not Intentletl or offered for sale ISec[ion 7044,Busincss Olhm�See Complete Fee Schedule)_ ►
and Professions Gode).
CONSTRUCTION LENDING AGENCY
I hereby atfirm that there is a construction lending agency for the
peAormance of the work tor which this permit is issued(Sec.3097, pERM1T FEE � (Sub-Totaq - �
Civ.C.1.
� PLAN CHECKING FEE � -
Lender's Name �
PERMR ISSUING FEE 5
Lender's Adtlre55 � �
I cert�fy that I have read ihis appiication and state that ihe a6eve TOTAL FEE Z�•s , - - ,
information is eorzecG I agree to eomply with atl Counry ordinances .
and State laws regulating Electrical wiring,and hereby authorizo
� representatives ot this Gounty to enter upon the above-mentionetl � � � �
property tor inspectian purposes. .
� SEE REVERSE FOR E%PLANATORY LANGUAGE . -
"'�2�J�,�Sn� �-i y�7
Signature ot Permittee. �ate
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, ._. '�.'. ,. ., C� .r- < , ' , . , „ _ ,
�. �. .,._-- �-----. .._ . ...: _ .,. _ ._.._. ... _._. ... . .----_ .
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'� , � ir�sNecTOR s � ---��t�����'NN�R-BUILDER'DEGIABAYION
�.`-��,'..•.��t�:, l ` � . �;.i .�� '„ ��APPPOVA�S � _ - DATE .. . -.� .. _ . .. _ __ ___. ..' .
_ _.. � � SICNATURE , t i,"�
� ��,.� c� �_� ,TEh,P�PO'?IER POLE _ � � _ I hereby zffirm that I am exempt Irom lhe Coniractor's Llcense
----- --- , ., � �Law for Ihe following reason(Section 7031.5,Business�tl
I v -.,��.�� �..ylND�RS 6 N✓ORK � -.' _. ._ l. __._ __ ._. - '�' , � . � FM/essibns Cade):Arry city ar eounty which re4urres a pemvt
� _.__._' _�� ' �.`_ _ .' . � to.eun;Luct��.,alte{,iTP'we,demolish,o[,�cp�ir�2(sf��ctwe,Pria
; '_ .. �ROUGH CONDU�T .'.�; . ___ _ .. __... i '� " , ��:
� ,•,.. _.,,._�, � � - fo�ifs/ssu.ancc,�a!so'repuires ihc appllrant for SLch crm,i!to�fifc
.__..____ . , �.
' , _N/IfiING�.� � � � '�, . i . -� , �� o signetl slntc.meM fhaf he is liccnsed pursvant to the prwisia�s
t --�--- -----��C��' FIXTURES�'' �--� . .. ,. . .._ . . . ; o/Ihe Contractor's�License Lmv fChapter 9(eomrtrencing wrN
-, .. _ __._ '. _ '._ •
';`� ,;���: .. . , � � 'Seetiron�7000 J ol Oi�ision'3 oi tho Busixss and P�ofossicns
'" `--° ' . �` ... - POVIER AUTHORIZEO-' .- - .. -- .�. . ._.-....-. . . �. _ ' Cotlel a�fhal Ac�ls�c�mmpt'them/rom e�d!be G�srs'/or the
� � -LrfILITY CO.NOTIFIED � � � � . '�� �.Reged exemption. Any viWafirn of Section 7031.5�by my
�� � �� �� � �� ��� � � � � I � , . �� �pplicant�a a permit subjecis the applicant�fo a civil penalty
(--�------- ------ -.._ .- -FINAL--- - --- - /_'tIlC')'OlI�Y071C ' - .....�- � � .�� � , . o!nof more fhan five hundred dopars l5500):' .
i , ' " ,_ � , ❑I,as rnvner qf thc property will do the work,and the
i _. ___ ___. ��.�.. ...._. uoTES . � _ _. . _.. '� i ,.�� . . ,. struc ure is not intentled or'oifered for sale.-- . ..
) � i 1
__„ ;.. ,�' ��,.,�i:_�t1';'� , , , ' �i , _ , , , � ' (SCC.704Q 8os�ne55 and Professions Code:�The Confroctor'S
v_ ' �
-- "- -- " `- "- � �Llcrose Law does not apply to an om�ner o/prcperty who builrls
i ..,� _
� �"�� '��;�`��. � � �'� � . � � " - � -� " or imprcr�es fhcrcon,antl who docs sueh vro�k himsetl pra✓idetl
. Y _ __. _ . . ...._ - '_'_'_ ' y .
. � �,l�` _,1�. \„` , Ihat sueh imp�ovcmrnts arc not infen�ed w olfcrcd for sale.!f,
I- - - ----- - �`-�� - , . -� .— - � Fmwever,the Cuild:n�or improvement is sold wifhin one year o!
. __ __ . comple:iai,the owner-bur7der vnii have fhe burdm of pronnc�[h�t
._ _ _.___ . __.. ..- ._,.... __.. _ _.. � �. � �he tl�tl nof build a Lrrprove!a ffie Purpose ol ez,'c.) '.
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- � ' � � ' ' � `�I,am ez�mpt under Sec.� `'' ,
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' B&P.C.for this reason ' �
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:- ,- �, � . ; - - -� � --- --- - � ... . ' �--- Date . _ _ -- . �
. . . . .. \ ' � ' Owner . . . � .
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