HomeMy WebLinkAbout1419A , WORKERS'COMPENSATIONDECLARATION ��� ���81 APPLICATION FOR ELECTRICAL PERMIT �
I herehy affirm ihaf I have o cartificate of consenl to self CE-806('
inwre,or a certificote of Warkers'Compensarion Insu�ance,� . COUNTY OF LOS ANGELES BUILDING AND SAFETY
or ce�.r{nfied copy th re f(Sac.3800,labr.�C.)
Pfi�N213�����Compony�/.]1[i�{�..d�1� FOR AP►ULANt TO RlL IN JOB
� Certified copy is here6y furnished. New Residential Bldgs.8 P ol EACH ta0. FEE ADORESS �
Carfifiad mpy is filad with ihe munty 6uilding inspeo- 1 8 2-Family,Sq.FI.� s — E �aA�ITY
tion deponmeni. Multi•family Sq.Ft. — NEARE57 -
� '�fa� ,�7Residential Swimming Pools CROSS 5T
�ate�{.�G�v��Appliconf ��y�����f�JY OWNEROR
n /J� FIRM NAqAE
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlels:RecLLi9ht � Sw. �! �'0'��
COMPENSATION INSURANCE First 20 ADOREu C��2 �
(Thls sectlon nMd not b�compl�t�d 11 fh�work inralr�d 6y Total No.� Additio�al CITY Tel.No. �
1hs p�rmif ls for on�hundr�d dollan(5100)ar In�.) PLAN CHKK
I certify Ihaf in Ihe performonce oi the work for which this APPIiCAM
permit is issued,I shall not employ any person in ony manner
so os to become subjeci to ihe Workers'Compeasaiion Laws. ��9hting Fixlures First�0 ADDRESS
Totol No.� Additional -
. �— CITY Tel.No.
�°�e �PP�'�°°t � Fixed Applioncas Not Ovar 1 HP FfRMIi
NOTICE TO APPLICANT: If, after making this Cartificole of APPIIGNT �
Exempiion, yov should become subject �o �he Wofke�s' Ronge_Heo�er_D.W._
Compensation provisions of the labor Code,you must forfh- Oven _Dryer —W.M._ ADDRESS f-�
wifh comply with such provisions or this permlt sholl be Top _FAU —W.H.—
deemed revoked. Hood _Fan _Other_ CITY Tel.No.
UCENSED CONTRACTORS DECIARATION � ucENs�pg �
I hereby offirm thot I om licensad under provisions of Chvpte�9 Disp. —Room Air Cond. _ REG-NUMBER Closs.
(commencing with Secfion 7000)of�ivision 3 of the Business power Appp�oWs&Large Appliances DISTRICT NO. PROCESSED_BY �
and Professions Code,and my licen»is in full force and effect. � /' O
Size 8 Type HP,KW,KVA,or KVAR �
License Number «�2�� Lic Class� Up to 1 Ind. � F�h1A� � V
�• Over 1 to 101nc1. DATE p yp��DAT10N �
Conhactor�'Y`N � ��Dale Z'{e'"�� Ovar IO to 50 Incl. � � a � V
❑ FINAL
I am exemp�under Sec. Over 50 to 100 Inc. BY �
8.8P.C.for this reason Over 100 y
Services,Swbd.,MCC 8 Panelboords ► - � ?
Date: 0-Z00 Amp.Under hW V � -
Signature � �01-100D Amp.Undar 600 V
❑ Ovar 1000 Amp.or Ovar 600 V
Exemption for Reg.Main�.Elect.
SINGLE FAMILY Temp.Powar Pole 8 Appurtenances
HOME OWNER-BUIIDER DECIARATION Sign wilh One Bronch Circuil
I hereby aftirm ihot I om exempt(rom ihe Conirotbr's License Addilional Sign Branch Circuils �5� Q�,9�,
Law(or Ihe following reasan($eclion 7031.5,Businass and -
.Professions CodeJ: �,��� e � �2
❑ I,os owner of fhe p�operty,will do Ihe work and the M;s<.Conduils 8 Conductors -
struUure is not iniended or oifered for wie(Setlion O�her(See Complete Fee Schedute)_ ► �,• •�O.6 8
. 7044,Business and Professions Code). � . •,•£Q 6 8`
CONSTRUCTION IENDING AGENCY .
I hereby affirm thot there is a construclion lending agency for 0 2 D�—8 4
ihe performance of the work for which this permi�is iss�ed PERMIT FEE (Sub-Totol) ?
(Sec.3097,Civ.C.).
!�� �,I,� I`„� PLAN CHECKING FEE � . _
Lender'sName I'�4J1lJVLl(PG
`�Z�,���� �,/� PERMIT ISSUING FEE � � , _
Lender'S Address��–
I certify thot I hove reod ihis opplication,and state ihot Ihe TOTAL FEE �
above informotion is co�rect.I ogree to tomply with oll Counfy
ordinonces and State laws regulating Electrical wiring,ond
hereby outhorize repraseNatives of lhis County to entar upon � � -
the above-men�ioned property for inspection purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE .
SignoNre of Per in �pOfe .
AFPROVALS -DATE � , _ � OWNER-BUILDER DECLARATION
. . - $IGNATURE - � .
� TEMP.POWER POLE ' , � I hore6y affirm thaf I am exempf from tho Contractor"s
� � . Liconse Law for tha follawing reason (SecNon 703F.5,
UNDERSLAB WORK Buslness and Prolosslans Code):Any c�ty or county which
ROUGH CONDUIT 3 - . reqvires a porm�t fo consiruct oltcr,Improvo,demolish.
� . , . or repalr cny sfru[}urc,prior to lls Issvanre, 'also re-
. �, � WIRING �' _ qulresfhaopplicorttforsuchpormlttofilvaslgnedsfato�
- . FIXTURES - _ _ . _ _ - menf fhaf he Is Ifcensadpvn�anf lo f6e provlzlons ol fhc
_ � . , Gontracfor's L4onso Law(Ghaptcr 9(commencln�w��h
� � POVJER AUTHORIZED � Secllon 7000)ol Dlvislan 3 0!tbo Eustness and Proles-
. slons Codv)or thaf hc k exempt�hemfrom and the bosis
� � UTILIN CO.NOTIFIED /or fhe alleged exempflon. Any violaf7on o!Secfion
� FINAI � c7 70J1,5 6y any appllcont for o permit evb�eds fhe appfi-
Gnfcr on .yranl canf fo a eivil penalfy of not moro ihcn Ifve hundmd
- - NOTES � � dolfors($500).: . �
-� . � ❑I,as owner of tho property wlll do the work,ond
- � � the strudure Is not intended or offered for sale.
� � � � (Sec.704�,Bosiness artd Profosslorts Code: 7ho Contrec-
"- - -- - - . lor's Llcense law does nof opply to an owner ol property
who bullds or Improves }hereon, ond who doez svch
� work hlmsel/provlded thol suth Improvemen}a ore nol
.. ...- _ . , Intended or offered/or tale.ff,however,the 6Wlding or
Improvemen!Is sold withln one year ol complofion,fhe
ownerv6ulfdorw1lf hovo the 6urden ofproving fhaf he d�d
- � nof 6uild or improvc/or fhe purpose of sa/e.)
I am exempt�nder Sec. ,
B&P.C.for this reason
. -. ..- ' . � Date '
Owner
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