HomeMy WebLinkAbout1417A (7) -- - - _ _ - -- -- . _ . __t
WORKERS'COMPENSATION DECLARATION �� ���8, � qpp��CATION FOR ELECTRICAL PERMIT �
I hereby offirm Ihof I have a cartificate of conseat fo self �E'�c
insure,or a ccutifica+e of Workers'Compensa�ion Insurance, � COUNTY OF LOS ANGELES BI�ILDIN(�a AN�SAFETY
or a �i' are 3800,Lob.C.) �
'f°`G�`P.s�''�a��Y� �.�t�IJ�
P�olicy No. COmpany FOR AtPIIGM TO fILL IN JOB
Ce�tified copy is hereby furnishad. New Residential Bldgs.8 P ols EACN NO. FEE ��� �� �
� � Cerlified co is filed wifh Ihe count buildin ins 1 8 2-Fomil FL s •Q — s LOCAUTY
PY Y 9 Pac- Y,SQ�
tion depanmenl, Multi•fomily Sq.Ft. — NEAREST
� Residentiol Swimming Pools Ow FR OR
Da�e �'� Applicom � D
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outleh:Rec 2 Light�Sw.� 'W`�� �
COMPENSATION INSURANCE - � ADORESS �
Thla a�Mfon nwd mt 6�rnm I�»d if fh��nork inrolv�d b N Fint 20
� P y Totnl No.._�.C_ CITY . Tel.No
th�p�rmH Is For en�hundr�d dollan(SI00)or bu.) Additional
I certify Ihpi in the periormonce of tha wo�k for which�his qppNj�M�
permit is issued,I shall not employ ony person in ony manner
so as to bacome subjact to�he Worke�s'Compeasation laws. lighting FizNras First 20 ADDRESS �
� Total No.� Additional CITY � Tel.No.
Dafe 4pp�icaN Fized Applionces Not Over 1 HP PERMIT �
NOTICE TO APPLICANT: If, after making this Car�ificate of A?PUCAN7
Ezemption, you should batome subject to the Workers' Range_Healar_D.W._
Compenwtion p�ovis�ons of the Labor Code,you must for�h- Oven _Dryer _W.M.— AD�RESS
wi�h comply with such provisions or fhis permil shall be Top _FAU —W.H.—
deemed revoked. Hood _Fon _O�ha�_ CITY Tel.No. -�
LICENSED CONTRACTORS DECLARATION LICFNSE OR ll.J-z_z?J
I haroby affirm that I am licenned undar plovisions of Chapte'9 Disp. _Room Air Cood. — rtEG.NueneER \ f� ���g�
(commencing wiih Sect�on 7000)of Division 3 of the Business DISTRICT NO. PROCESSED
and Professions Code,o�d my license is in full force and eRecf. P�'"'er Apporafus 8 large Applionces �Y
,/y� Size 8 Type HP,KW,KVA,or KVAR lO Q
license Number �'"�'�Z�7 Lia Class � � FINAL - - V
Up to 7 Incl. �a�/��
' Contracto��� �'��a�e Z"'�"�— Over 1 to IO lnd. DATE VAUDATION Q �
O . Over 10 to 50 IncL FINAI — . . V .
I am exempt under Sec. Over 50 to 100 Inc. BY d
B.BP.C.tor this reason Over 100 Z
� Date: Services,Swbd.,MCC 8 Panelboords , �
0-2U0 Amp.Under 600 V �
SignaNre � 201-1000 Amp.Under 600 V
� Over 1000 Amp,or Over 600 V
Exemption for Reg.Maint.Elac�.
SINGIE FAMILY Temp.Power Pole 8 Appurfenances . .
HOME OWNER-BUILDER DECLARATION $�y�wiih One Branth Circuit
I hereby ofihm thar I am exempt from the Comractor's License qdd�rional Sign Bronch Circui�s r.1 4 1,7 A
Law for Ihe iollowing reoson�Seclion 7031.5,Business and � � �
Professions Code): , $;o . e • .2
❑ I,os owner of Ihe erf will do Ihe work pnd Ihe Misc Conduits 8 Conductors ' "��
P�� Y� Other See Com lete iee Schadule
slrocWre is nol intendad or offered for sala (Secfion ( P 1— � � •�_•.9 2 4 4
701a,Business and Professions Code). • • <S 2 4 4 c=i
CONSTRUCTION LENDING AGENCY •
I hereby afiirm�hat the�e is a construction lending oge�cy for I � 0 2 Q']-�(j
� the pertormance of Ihe work for which this pe�mit is issued PERMii FEE (Sub•To1a1J � - __-
(Sec.3097,Civ.C.). �
�..� ��� PLAN CHECKING FEE - �, . . .. �
Lender 5 Nome���—' � '
� PERMIT ISSUING FEE
Lender i Addreza"��,�ry�� � '
I cerlify Ihol I have read Ihis applicalio�and slole ihot the TOTAL FEE �
abova intormotion is cwrect I ag�ee lo comp�y wifh oIl Counfy ,
ordinances and Stote laws reguloling Elecfriwl wiring,and , , - .
hereby aulhorize rapresentotives of this Counfy ta eNer upon ' � '
the obove-menrioned r eny for inspection porposea. SEE REVERSE FOR EXPLANATORY LANGUAGE .
Ignature of er 1 Date ' ,
nPPROVALS DnTe- p OWNER-BUILDEP.DECL'ARATION
. � � SIGNATURE
� ' TEMP.POWER POIE � � — , I heraby affirm ihat I om exempi from iho Controc�oi s
- � - � ... � �icenec Lpw for fho following rcason (Sccf7on 703L5,
. � � UNDERSIAB WORK _ . . Buslness ond Professlons Gode):Any dty or county whlch
, ROUGH CONDUIT - �J � - � reqvlres o permlt to cons�rucf,alter,Improve,demol�sh,
�or repalrany strucforc, prlonfo I1s Osuanco,ofso rr
. . - � � WIRING � . quires the applfcant farsucb permH fo lile a s�gned sfafe-
� � � FIXTUkES � . � menf Ihat ha fs I�censedpursuant to tho proNslons ot eho
, Canfroctor's Llcenso Law(Chopter 9(commencing wlth
POVJER AUTHORIZED -" � Secflon 7000)o!Divlsfon?of fhe Busfness and Proles�
slons Codo)or fha�he Is rxempf fhcrefrem and ihe basls
�� -� UTILITY CO.NOTIFlED - � , . for the alfeged ezempffon. Any vlolalion of Secfion
- - - - - -��� FINAL � �+ c� . � 7031.5 6y any oppllcanf for e permlf subfecfs Ihe appli-
- Gnfer ors ,trortl � . canf lo a eWil portoHy ol nof moro lhan hve 6vndred
- - - - � NOTES - . doUcrs(b500J.:
� , , � � ❑i,os owner of iho property will do the work,ond
- - - � � ' � � � tho shucture fs not Intendad cr offorad for sale. �
. .' � - '� , (Sec.704l,BustnassandPro(oezfonsCodo: ThoConlrcc
- - � -� � - " rori Ltcenee Law does nof opply to on owner o!properly
_ _ . , . wbo bvilds or lmprovos Ifioreon, ond who docs suoh
� - � work fifmsalf providad fhat such Jmprovemen/s arc nof
. .. ... ' . � � infcndod or oHerod for sale.I!.howevor,1he bWfding or
� � � � improvemenY Is sold wRhin one yeor of complotlon,�ho
. � - , , . , _ ownervbvildoravl!!havc fhe burden ol proving fhet he did
' nof 6u�fd or Improvo for ihe purpose of salo.)
- � ' I pm exempt��der Sec. ,
B 8 P_C.for this rcason
— Da�e
Owner