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Home My WebLink About1413A WORKERS'COMPENSATIONDECIARATION 76A66� io�ei APPLICATION FOR ELECTRICA! PERMIT I hereby aifirm thot I have a cerfificote of consenl lo self CE-806C insur�or a certificate of Workers'Compensatian Insuronce, � COUNTY OF LOS ANGELES BUILDING AND S �( � � ' or a certified copy thereof(Sec.3800,Lab.C.) , , � ' Ocy No. Company FOR AV►LICANT TO FllL IN qppgESS p C-. �f � Ceriified copy is here6y fumished. New Residentia�Bldgs.8 Pools EACH NO. FEE � Certified copy is filed with Ihe county building Inapec- 1 8 2-Fomily,Sq.R. 5 — £ LOCALITY �pNy ��ly, tion department. � . Muhi-family Sq.Ft. — �A�ST CRO55 ST. T) � Date Applicant Residentiol Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF ExEMPTION FROM WORKERS' � � MAIL � WMPENSATION INSURANCE Outlets:Rec_lighf w. qpDRESS . SA-�Y!� (Tbis t�Nion nNd not be compld�d i4 tb�work invoiv�d by First 20 fh�pumit l�for on�bundnd dollen(SI00)or Int.) Total No. Additional CITY 'n Tel.No. � I cer�ify thot in the performonce of the work for which�his , PLAN CHECK permi�is issued,I shall not employ ony person ony monner APPLICAM v .-✓1 , so os�o become subjed to the orkers'Com mion Laws. Lighting Fizrures First 20 ADDRESS f,9s/ /j, � S��('� Total No. Addirional Date-�'��'� ��icant CITY Tel.No. 3 7� NOTICE TO APPLICANT: If, after moking Ihis Certificate of Fixed Applionces Not Over 1 HP PERMIT . Exemption, you should 6ecome su6ject lo the Workers' Range_Hea�er_D.W,— APPIICAN7 . Compensation provisions of ihe Labor Code,yov must for�h•� Oven _Oryer _W.M._ ADDRE55 � with comply with such provisions or ihis permit sholl be Top _FAU _W.H.— deemed revoked. � � CITY � Tel.No. LICENSED CONTRACTORS DECLARATION Hood _Fon _Other_ Disp. _Room Air Cond. — LiCENSE OR c/ c � Class.G f/3 I hereby affirm tho�I am licensed under provisions of Chapter 9 REG.NUMBER 7 � /�f� (commencing with Section 7000)of Division 3 of the 6usiness Power Apparaius 8 Large Applioncas DISTRICT NO. PROCESSED BY ond Professions Code,and my license is in full force and effect. � . a � _�3 Size B Type HP,KW,KVA,or KVAR � License N�mber � Lic.Class Up to 1 Incl. FINAL �7 Contractor pote�17`�R �' � ��er 1 io 10 IncL �p'T I� � VqLIpAT10H � ❑ Over 10 to 50 Ind. - � FINAL ��I am exempf under Sec. Over 50 to 100 Inc BY W � 6.8P.G.for this reason Over I00 q' ' � Services,Swbd.,MCC&Panel600rds � -- ,� � � z Date: 0-200 Amp.Undor 600 V Signature � 401-1000 Amp.Under 600 V ' � aOver 1000 Amp.or Over 600 V � Exemption for Reg.MoinL Eled, SINGLE FAMILY Temp.Power Pole 8 Appurfenonces HOME OWNER-BUILDER DECLARATION Sign wiih One Branch Circuit . ��'� [�� 3 A I hereby aff�rm thai I am exempt from the Contractor's License Addilional$ign Bronch Circoils Law for ihe following reoson(Section 7031.5, Business and �a � � � �.� Professions Code): , ❑ I,os owner oF the property,will do the work ond the Misc.Condoits 8 Conduc�ors � ' � •-y�O. .Jr 0 . � slructure is naf intended or offered ior sale(Section Olher(See Complete Fee Schedule)_ . 7044,B�siness and Professians Code). � , � ', • ° •J Q J�Q c=i CONSTRUCTION LENDING AGENCY O�I�� S-S J� i hereby affirm that there is a construction lending ogency for ' the performante of Ihe work far which ihis permit is issued PERMIT FEE � � - �- ($ub-Totol) � . (Sec 3097,Civ.C.J. � - PLAN CHECKING FEE Lender i Name PERMIT ISSUING fEE �U � Lender's Address '- I cerlify that I have reod this applicalion ond state ihat the . TOTAL FEE �O �. obove iniormation is correct.I agree�o comply wilh oll County ordinonces and Sta�e laws regulaiing Elecfriml wiring,ond hereby outharize represeniatives of�his Coonty to enter upon � th o6ove-m tioned property for inspecfion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �� $� � Siqnoture of Cerm� ee Date . i � � , � . AVPROVAlS DATe � � � OWNER-BUIIDER DECLARATION . � SIGNATURf ' � � � TEMP.POWFR POLE I hereby affirm thot I am exemp�from�ho Gontrocror's . - � � license Law for Ihe following rea:on (Socflon 7031.5, UNDERSIAB WORK Bu3lne�s and Prolosslons Code):Any city or caunfy whtch ROUGH CONDUIT requfres a permit to eonsfrucf,alrcr,Improvm demoUsh. � __.. � _' or repair ony sfrodure,pr�ar fo Bs issucnce, afso�ro- � WIRING . qulres fhe oppllconl for such permll!o flfe a sfgned sfafe- - - men!Thaf he Is llcensodpursuanf}o Ihn provislons ol fMe , FIXTURES . �Confracfor's Llcense Law(Cbapter 9(commendng with ' - � POWER AUTHORIZED Setflon 7000)o/Olvlsfon 3 0/fho Ouslness and Pro�es- " stons Code)or lhof he ls excmpl fherefrom and fhc basls -� UTIUTY CO.NOTIFIED � ' lor fhe aNeged oxempNon. Any viofairon o/Sec�ion ' ' iINAL � n 7031.5 by any appficanf lor a permlt subfvcfs tfie apph- Gnfrr on��onl ' cani}o a civtf ponvlty of nof moro IFan flve hundrod � - � NOTES dollars(SSOD).: ,' ' " ❑I,os owner of the property will do Iha work,ond � -- � iho strocturc fs nol inlended or offerad for sale. _ . . � (Soc.704�,guslnoss and Prolesslons Code: iho Confrac �or's Ucense Low does not opply eo an ownor of property � - -- . . . - who bullds or lmproves �hereon, and who does sucF work hlmself provlded fhat such fmprovements orv nol ' � ' ', . , � � fn�ended or o/lerad lor sale.If,however,tho 6olfding or � improvemanf Is sofd wllbin one year of compleMon,fhc � � � . � awner-builderwilfhavethoburdenofprovinglhathedid � ' � � nof bWld or imprave(or 1he purposo of sofv.) i,am exempt under Sec. , + B&P.C.for this reason Date Owner