HomeMy WebLinkAbout0825A (4) WORKERS'COMPENSATION DECIARATION �6A�� �o,a� qpp��CAT10N FOR ELECTRICAL PERMIT j�
� I hereby affirm thai I have a cerrifimte of consaM ro self �E'� ,
insure,or a certifica�e of Workers'Compenwtion Insurante, �OUNTY OF�OS ANGElES BUILDING AND SAFETY ��
or a cerfified copy Ihereof(Set.3800,Lab.C.) ,
P�olicy No. Company fOR At►LICAM TO illl IN 109 �7 � n
Cartified copy is hereby furnishad. New Residential Bldqs.&Pools EACH NO. FEE AooRE55 p � ��/T�
� Certified copy is filed with the county boilding inspec- 1 d 2-Fomily,$q,F�. s — s �OCA��TY D � '
NEAREST
tion deparlmeM. Muhi•family$q.FL CROS557. /' � �
Dale Appliconf Residenlial Swimming Pools �bEa� .
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec�Lighf 3. $w,I� iNP��t
COMPENSATION INSURANCE A�E�
' First 20 ��D
(Tbis s�chion nwd not b�complN�d lf th�werk invelv�d by Total No.� Addttional CITY � Tel.No.
ffi�pnmlt b for ona hundnd dollars(5100)or Ins.} p�qN CHECK
I cenify that in the performance of the work fa�which this ' pp���qM �
permii is issuad,I shall not employ any person in any monner
so as to become sobject to fhe Workers'Compenwtion laws. Li9hting Fixtures First 20 ADDRESS -
Total No. � Additional
Date APPlicant � CITY Tel.No.
NOTICE i0 APPIICANT: If, ofter making Ihis Certificote o{ Fiaed Appliances Nol Over 1 HP A�M�CANT /7� �
Exemptian, you should become subjec� to the Workers' Ronge_Heater_D.W._
Compenw�ion provisions of 7he Labor Code,you mus�forth- Oven _.Drye� —W.M.— ADDRE55 3�-6 p,�y�,� ,Qy �
wifh comply with such provisions or this permit sholl be Top �.FAU —W.H.— C�� o pZ7��7
deemed revoked. CITY Tel.No.
. � LICENSED CONTRACTORS DECLARATION Hood _Fan _Othe�—
Disp. _Room Air Cond. — LICENSE OR CIa
I hereby offirm thar I om licensed under provisions of Chap�er 9 REG.NUMBER S �� �1
(cammencing with Seclion 7000)of Division 3 of Ihe Business powar Apparpt�s&Large Appliances DISTRICT NO. PROCE D BY �
and Professions Code,ond my license is in full(orte and effecr. b
S� /� Size 8 Type HP,KW,KVA,or KVAR �� �
License Number O ia Closs Up l0 7 Ind. DA EL � � �
� � Ovar 1 to 101nc1. � �� VALIDATION Q
Contracror a�e Ove�10�0 50 Incl. � f-
❑ FINAL
I om exempt vnder Sec. Over SO to 100 Inc. 8Y F ` �¢� W
"" B.BP.C.for Ihis reasan �Vef�� , N
Services,Swbd.,MCC 8 Panelboards , z
Dale: 0-200 Amp.Under 600 V - �
Signolure 201-1000 Amp.Unde+600 V " ;
� Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect. � :�Q$2�J a
$INGIE FAMILY Temp.Pawer Pole 8 Appurlenpnces �e e e o •`2
HOME OWNER-BUILDER DECLARA110N Sign wilh One Branch Circuit �
I here6y offirm that I am exempt irom 1he CoNrocfor's License qddilionol Sign Branth Cirtoits � ° °� �.7�J
Law for Ihe following reoson(Section 7031.5,Business and '
Professions Code): • 1 &7 .Jr�
❑ I,as owner of the property,wi�l do the work ond tha Mrsc.Conduiis 8 Conduc�ors , • �
slrotlure is nof i tended or offered for sale ($eUion Other(See Completa Fee Schedole�— ► � 0�.b 3—S 4
7044,Business and Professions Code). �
CONSTRUCTION IENDING AGENCY � - --
I hereby affirm ihat there is o consrruction lending agenty for .
the performonce of the work for which this permit is issued PERMIT FEE � (Sub-ToialJ .� - . -
(Sec.3097,Civ.C.j.
PLAN CHECKING FEE � ;
lender's Nome �
PERMIT ISSUING FEE ,y �
Lender's Address
I certify thai�hove reod this appllcation ond state that the TOTAI fEE �.75 �
obove infarmation is mrrect I agree to mmply wilh all CouNy
ordinances and Stale lows reguloting Electriml wiring,and -
hereby outhori representotiv s of this County to enler upon . ' �
th e-m d rope for inspection purpose. _ SEE REVERSE FOR EXPLANATORY LANGUAGE �
• �i 1�3-8� ,
ignoture o Per i lee Da�e .
- � �-� '�' � �APPROVALS pAre _ _ _ . � . . _ OWNER-6UILDERDECLARATION
SIGNATU�F
• � TEMP.POW'ER POLE � � ' �' I hcreby affirm that I om exempt from the�Contracror's
- � - � ' - - Licenso Law for tho following reaaon (SecNon 7031.5,
, . � '- , . , UN�ERSLAB WORK � Buslness and Prafesslons Codc):Any dty or county whlch
ROUGH CONDUIT - - � � requires a parmlt fo cansfruct,a(ter,Improvo,domohsh.
or repotr any efrucfurc,pNor fo Its Isevonre, a6o re
WIRING .. quiros The applkani for suth permlf fa life a s�gned stofe-
�. . .. � � men}lhat Rs Is 11[onsedpursuant to Ihe pravislons of Iho
FIXTURES � � � , Contractor's Ucenso Caw(Choptcr 9(commendng wi�h
- POW'ER AUTHORIZE� � Svction 7000)of D(vlslon 3 0/fhc QUSIpf55 and Pro/es-
. � slons Code)or fha}he�s exempf fherclrom ond ffie bosls
- - UTILITYCO.NOTIFIED for Ihe aqeged oxemptlon. Any violatton ol SecNon,
� �� -�- - FINAI �n(c�on �"�nnf ' 7031.5 by any applitanf lor a permff svb(ects iha appli-
cant fo a clvll pcnoffy of nof more Ihan/ive hundrod
� - NOTES � _dollcrs(5500).:
, . . . . - � � ❑I,os owner of tho property will do the work,and
� - ' � � iho strucfore Is not iMendcd or affcred for solo. �
_ , , ., , . , , , -- -� (Sec.704�.Business artd Prolosslons Code: Tho Conlrac
- - � -- for's Llcense Low does nof appfy fo on owner o1 properly
- � ..- � � � � _ , wfio 6uifds or lmproves thercon, and who does such
� �•'•, work hlmseH providad Ihaf sucF Improvomanfs arv nol
. ._ . . Intendod or offered(or sale.If,however,fhe bvlldfng or
' Improvemen}!s sold wlfhin one yoor of complefion,Ihe
. , . . � owner-bolfderwfl!havo the 6�rden of prov7ng fhat he did
� � - not bulld or Improvc lor 1he'purpose of salc.J
� � �� I om exempt under Sec.� ,
.. .B 8 P.C.far this rcason
�
- - , - Date ' -
, Owner
- .. . ,- _` . . ` ,