HomeMy WebLinkAbout1412A WORKERS'COMPENSATION DECIARATION 76A663 ,o�a� .APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm thai I have o cer�ificate aF consant to self CE-806G
insure,or a certHicaie of Workers'Compenwtion Ins�rance. COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thareof S 3800,Lab.C.)/�� /�
p��l'��y Na�31e���y�t'(11.�1J FOR AP►IKAM TO fILL W � �� • �
Certified copy is hereby furnished. New Residenfial Bldgs.& ool EACH NO. FEE A���
Cerl'rfled copy is filad with Ihe touNy build�ng inspec- � 1 8 2-Family,Sq.FI.� s — S �«ALIN �N`.�
tion da rim nL Muhi•family Sq.FI.� NEAREST :�
L�'/� Residential Swimming Pools OWNER OR� � p
�e�Z���Applicaat�--�{�,�.�c�P /f FlRM NAME '7 Ll.
CERTIFICA7E OF EXEMPTION fROM WORKERS' Outiats:Rec�Light�Sw.v �''°'�� �
COMPENSATION INSURANCE � � � nDORE55 �.
First 20 + �
(Tbis toellon n�ad nof 6o complN�d fi fh�work Invelwd by 7otal No.� Addi�ional CITY Tel.No
1h�p�rmH 1�for on�bundnd dollan(SI00)w Int.)
PIAN CHECK
I certify ihat in Ihe parformance of the work for which�his qprucqM
permit is issuad,I shall no1 amploy any person in o�y manner
so as to become subjec�ro�he Workars'Compensalion Laws.� Li9hting Fiztures] First 20 ADORESS �
- Tolal No._(_ Additional CI1Y Tel.No.
Do�e Applicant Fixed Applionces Nol Over I HP " PERMIT
NOTICE TO APPUCANT: If, after making this Certificate af APPUCAM
Enemption, you should bacome subj«t to the Workers' Range_Hea�er_D.W._
Compensation provisions of ihe�Lobor Code,you must forlh- Oven _Dryer —W.M._ ADDRE55
with comply w'th soch provisions or lhis permit shall 6e � Top —FAU —W.H.— ,
deemed revoked. � Hood _Fan _Oihar_ QTY Tel.No.
' LICENSED CONTRACTORS DECLARATION LICENSE OR
I here6y aHirm iha�I am licensed undar provisions of Chopter9 Disp. _Room Air Cond. — REG.NUMBER� � - Clou.
(mmmancing wi�h Section 7000)of Division 3 oi ihe Business Power ApparoNs&Large Applionces DISTRICT NO. PROCESSED Y ,r
and Professions Code,and my license is in full force and effect. / d
n Size B Type HP,KW,KYA,or KVAR !� �
License Number�'7"�'+�-�� Lic,Class � Up to 1 Incl. F�N'DA V
��p+���j7 yy�n�� � Ova�1 to 10 Ind. DATE 3' p O� yp��DAT10N Q
Controcto}-�.iL�7��R11{.I L aie Over 10 to 50 IncL FINAL / Q V
❑ I am exempt under Sec. Ovar SO to 100 Inc. BY W
6
Over 100 y
B.fiP.C.for this reason , , 2
- Dole: Services,Sw6d.,MCC 8 Panel6aards - - - `
0-400 Amp.Under 600 V
Signoture 201-1000 Amp.Under GW V �
❑ Over 1000 Amp.or Over 600 V �
Exemplion for Reg,Moin1.Elacf.
SINGLE FAMIIY Temp.Powar Pole 8 Appurtenances � . 1,
HOME OWNER-BUILDER DECIARATION � Sign with One Bra�ch Circuil � � 4�,2 A
. I hereby affirm tha�I am enempt from Ihe CoMroctar's Licanse Addifionol Sign Branch Circuils � � �• • • • •'Z �
law for the following reason(Section 7031.5, Business ond
Professions Code): � � • •9 5.4 4
❑ I,as owner of the properry,will do the work and the Misc.Conduits&Conductors
shucture is no� intended or of(erad for wle(SaUion Oiher(Sae Complete Fee Schedule)_ , . • e •9 5 4 k�
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY .O Z O 7'H A
I hereby offirm Ihot there is a construclion lending agency for
the performance of the work ior which Ihis permit is issued PERMIT FEE .(Sub-Tolal) � -
. (Sec.3097.Civ.C.).
PLAN CHECKING FEE - � � �- �
� Lender"s Name � , .
� � � PERMIT ISSUING FEE . . _. . .
Lender's Addreu �
' I cer��fy�ha�1 have read this applimtion and srote ihat the TOTAL FEE � . _ . __
a6ove Informa�ion is mrreU.I agrx b comply wi�h oll County
ordinances and S�ate laws re9ulating Eleciriml wiring,ond ,
hereby authorize representatives of fhis Counly to enter upon �
1 ve-mentione properly for inspection p�rposes. � � �
SEE REVERSE FOR EXPLANATORY LANGUAGE
� ignature of rmitt e ��
. � �APPROVALS �ATE _ _ _ � . , . 'OWNER-6UILDER DECLARATION
��- . , - SIGNATURE .
� �� TEMP.POWER POLE " , � I hareby affirm ihat I am cxempt from the Cantrcctor's
�� - �� ' � - � Licenao law for tha followinq roason (Soctlon 7031,5,
� � UNDERSLAB WORK .. . Buslness and Professions Code):Any ci�y or counfy which
. . ROUGH CONDl11T - j, — � � � requlres apermR to canst�ocf,alter,Improve.�demolfsh,
. . or�epofr ony slraduro,pNor to fls Issuonco, olso rr
� , WIRING � _ quires fhe eppOcant tor such permll fo lile a slc�ned sfata-
�� FIXTURES � � . � ment fhot F�e tt flcentedpursuant!o tho prov(slons ol!he
\ . � """ ' � _ �Coniracfor's L(cense Cow(Chopler 9(commencin�wuh -
� " - POWER AUTHORIZED � - � � Socllon 7000)af D!vlsion 3 of lhe Buztness and Profes-
� sions Codef or fhaf he Is exempt Iherefrom and�hc basis
� - UTILINCO.NOTIPIED (or ffie alfeged oxemp/lon. Any vlolatlon ol Secfion
- � FINAL� - ��nler on .�'�nnl '� 7031.5 by any apphcanf for a permlt subfecfs}hv appli�
� • cont to a elvif panahy ol not moro fhan Ilve hundred
- � NOTES � dollan(S500J.: .
� . . ❑I,as owncr af tho property wtll do the work,and
- - � � ' � � - . fhe structure(s nat Infendad or affored for salo.
� , . � - - . (Sec 704�,Bualness ond Pro(essions Codo:. The Controc�
� ' for's L(censa Law does nof apply to an owner of property
_ _� __ _ � . who 6vilds or Improves fherean, and who does sucb
work hlmself provfded fhol such Improvemenh are nol �
� � � � �� ' - '-� � intended or olfered(or sale.f/,howevcr.Ihe bulfding or
� �mprovemen�!s sold wuA�n ane yeor of complotion,�he
, _ , . � , � � owner-6ullderwlllhavetho6urdenolprovingfhofhedid
- ' '� � na�6ui1d or Improvc/or}he purpose of salv.)
� ' � -.I am exempt�ndcr Sec. ,
B&P.C.for ihis raason
Dafe
Owner