HomeMy WebLinkAbout9462A (21)- -; WORKERS' COMPENSATION DECLARATION _;.
1081 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I 'have a certificate of consent to self
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insure, or.a certificate of Workers' Compensation Insuronce,
or o certified copy thereof (SeA31ob -
COUNTY OF tOS ANGELES
B L I AND SAFET
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Policy No.�om
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_ FOR APPLICANT. TO FILL IN
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ADDRESS210
Certified copy. is hereby
New Residential Bldgs:�. P�r.o�oh�s..,�,,.. ��
- EACH MN. FE E
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Certified copy is filed wui ding insper
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LOCALITY
' Pion epartmeni.
Date Appic
- MuHi fomlly Sq Ft. �-
- Residential Swimming Pools
NEAREST
CROSS ST.
-
OWFIRN MEC
RT�IFICATE OF EXEMORKr''�+
COMPENSATIOWINSURANCE -
Outlets: Reclighfl' S
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ADDRESS 5A..t . l:
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First 20
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(Thissectionneed not be completed If the work Involved b Y
fhe dollars
Total No. Additional
CITY Tel. No. ?C— g
Permit is far one hundred (3100) or kss.)
1 certify that in the performance t rkfor which this
- permit is issued, 1 shalt not a any manner
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�NC�NGC
i
as becomes pact to tr nsation Laws.
yAdditionalL t.' -
LlghNng Fixtures First 20
Total No.� _
ADDRESS
CITY _- Tel. No.
ote pplic
NOTICEAPPLICANT: If, after making' this -C i irate of
Fixed Appliances Not Over 1 HP
-
PERMIT
.TO
Exemption, you should become subject to the orkers'
_ Range Heaters D. W.
APPLICA
-
Compensation provisions of the Labor Code, you must -forth-
_ Oven —Dryer _ W.M. _ -
ADDRESS
.with comply with such. provisions-or�fhis .permit shall be
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CITY -Q TeL
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Hood �. Fon _Other_,
-
LIC CONTRACTORS
LICENSED CONTRACTORS DECLARATION
ORS D LARAon
Roam Air Cond.
LICENSE OR
3(0
Class.
tdhe hereby that l
y provisions of Chapter 9
-�Disp. -- .`.
REG. NUMBE -
-
_
(commencing with Section 7000) of Division 3 of the Business
-
Power Apparatus &Large Appliances..
. -
DISTRICT NO.
PROCESS BY !
.and Professions Code, and my license is in full force and effect.
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License NumberSd�(Y. �Lic. Class'nes
Size & Type, HP, KW, KVA, or KVAR'
- -
FINAL
fJ
- c - ktZd(k Y g'
Up to 1 Inc,..
.....-,---- - Over 1 to I5 Incl
�ry "
DATE !-�
VALIDATION i 0
�
I Contractor Dote _
-
Over 10 to 50 Incl.
FINAL
❑-
I am exempt under Sec.
Over 50. to 100 Inc. ..:
-
BY,.-
Lu
BAP.C. for this reason
: Over 100
_
! _
Date:
Services, Swbd.;MCC &Ponelboards
® ---•
0 - 200 Amp. Under 600 V
Signature
._:201'- IWD Amp. Under 600 V-
.Over 1000 Amp, or Over 600 V
Exemption for Reg, Malnt. Elect.
'-' - --
SINGLE FAMILY
Temp. Power Pole &Appurtenances
Oeason
Sign with One Branch Circuit
I hereby affirm that 1 agm exempt from the Contractors License
Low for theHOMfo oE p5eariou 7037?SO Business and
Additional Sign Branch Circuits
_ ;99462A
Professions Code): -. -
`- -
# • ° r . ,•
I, as owner of the property, will do the work and the
Misc. Conduits_& -Conductors
-
'
( ° 09.7
structure is, not intended or .offered for safe (Section
Other (See Complere Fee Schedule)_
-
7044, Business and Professions Code).-
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' CONSTRUCTION LENDING AGENCY
' f hereby affirm that there is a construction lending agency for
1 G07-8 3 ',
,. - the performance of the work for which this permit is Issued -
PERMIT FEE - -• - -(Sub-Total)
(Sec. 3097, Civ. C.): - -
-.
PLAN CHECKING FEE
Lender's Name
'-
- PERMIT ISSUING FEELender's
-
Address
I certify that 1 have read this application and state that the
TOTAL FEE
�- 'on is correct. I agree to comply with all County
State laws re sting Elctrical wiring, .ande
`
represent es of this County to enter upononed
Adinc
pr ty for inspection purposes.
TEE REVERSE LANGUAGE
FOR EXPLANATORY E
_
Signature of Per a Dqtaf
01111Fr + 'i.,:+r a -e.pr.in-
. l ,k "VImo m abeam- ----* a rte...+: r elm.
- _
y� sli We r/r die
t,.,, IA,PPRQVAL5' - .DATE INSPECrowb
SIGNATURE .:
TEMP. POWER POLE
UNDERSLAS WORK vN
ROUGH CONDUIT;
WIRINWIN
G
FIXTURES
POWER'AUi ORIZED .__ ...
UTILITY CO. NOTIFIED
P(+
FINAL
!OWNER -BUILDER gECIA TI
c... I. hereby affirm that 1 am exempl from the Contractor's
- - Licensee Law for the following reason (Section 7031.St
- ...... �' - Business and Professions Code): Any city or county which
requires'a permit to construct, alter,. Improve, demolish,
_ or repair any sfructure,'prlor to Its Isluance; also 're-
quires the applicant for such permit to fire a s4ned state-
' - - moot that he is licensed pursuant to the provisions of the
Contractor's License Low (Chapter 9 (commencing with
- - - Section: 7000),of Division of the Business. and Profes-
sions Code) or that he isexempt therefrom and the basis
for the , alleged exemption. Any, violation of Section
- . 7031,5, by any applicant fora permit subjects the appli-
cant to. Nvll eenelty of net morethan five hundred