HomeMy WebLinkAbout1592A WORKERS'COMPENSATION DECLARATION 76A6E3 ,o.a, APPLICATION FQR ELECTRICAL PERMIT �
�=I.he�e6y affirm Ihof I have o certificale of consenl to_self CE-B06('
iosure,o�a cenifiwre of Workers'Compensa�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o cenified�c y�thereof(Sec.3p-�yy�-�-ab.C.) �'C
P�al��cy No.1GLlII�Company��'��"'""`� y FOR A►PLICANT TO flLl IN � � .lOb
Certified copy is here6y furnished. New Residential Bldgs.8 Pools EA�H NO. FEE /ODRE55 L
� � 1 8�-Famil Ft. . 5 = E IOCALITY . � ..
Certified topy is filed wi�h ihe couniy build�ng inspec• Y�,�9���
tion depoAment. Mull�-fomily Sq.-Ft.�_ � NEnrtE51 .
_ Residenliol Swimming Pools CROSSST.� �
, Date Applitan� OWNER OR .�u t
.. FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' rr.,nu p D�
Outlets:Rec_Lighl_Sw._ � G
COMPENSATION INSURANCE - � - nooRESS S .C. �
This��cflon nMd nof b�com 1•f•d if Ih�work Invol.�d 6 First 20 ��
( P Y Total No. Additional CITYAA Tel, o'j��
tb�p�rmit h for on�hundnd dollars(SI00)or I�ssJ ,
I certify thol in the performonce of the work for which Ihis . � APPLICANTK
permit is issued,1 sha�l not employ any person in ony manner
so as�o become subject to the Wa�kers'Compensation Laws. lighling fixfures First YO ADDRE55 �
� � Total No. Addilional
Date e IicaN CITY Tel.No.
PP Fixed Applian[es No1 Over 1 HP PERMiT
NOTICE TO APPLICANT: If, ofter moking this Gertificale of APPIIUNT L( �
Exemption, you should become su6ject �o the Workers' Range_Heater_D.W._ �
Compensa�ion provizions of the Lobor Code,you musl forih- Oven _Dryer —W.M.— ADDRE$ C �
with comply with such p�ovisions or th�s permit shall be Top _FAU —W.H._ �
CITY iel.No.
deemed revokad. . � - � D�
Hood _Fan _Other_
UCENSED CONTRACTORS DECLARATION . LiCENSE OR ( —
1 hereby affirm tha�I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER� 1� � C�au� �
(commencing with Section 7000)of�ivision 3 of Ihe Business DISTRICT NO. � PROCES BY
. and Professions Cade,and m license is in ivll tarce and effecf. �- Power Apporotus&large Applionces { .�/� Y
Y q"� �/{� Size&Type HP,KW,KVA,or KVAR /O \\\ � Q
License Number�� ���� `� Lic.Closs "r� ' Up to 1 Ind. � FINAI - � V
Confracror Date - Over 1 fo 101nd. DATE g�� 3 VAUDATION . O
❑ Over 10 to 50 Incl. V
FINAL,
I am exempt under Sec Over 50 to 100 Inc. BY � w
6.8P.C.for this reason Over 100 ��� V�i
� Services,Swhd.,MCC 8 Panel6oards � � ?
Da1e: � 0•200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V ,
❑ Over 1000 Amp,or Over 600 V
Exemplion for Reg.MainL Elect. �'� 5 9.2 A
SINGLE FAMRY Temo.Power Pole 8 Appurtenances � , � �
HOME OWNER-BUILDER DECLARATION Sign with One Branch Cirwii #• • • • •2 .
I hereby affirm tha�I am exempt irom the ControUor's license Adduional Sign Branch Circuiu
Law for ihe following reason(Section 7031.5, Business and " � • •2 rj,5 Q
Professions Code): . � . �
- ❑ I,as owner of the property,will do the work and the Misa Conduits 8 Conductors � • • •2 5.rJ��
structure is not intended ar offered far sale(Seclion ��her($ee Complele Fee Schedule)_ , �7,G L��i Jr
7044,Business and Professions Code). .
CONSTRUCTION LENDING AGENCY
I hereby atfirm ihat ihere is a construc�ion lending ogency for
the periormance o(the work for which�his permir is issuc�tl � PERMIT FEE (Sub-Taial)
(Sec.3097,Civ.C.). �'r'��
�� PLAN CHECKING FEE ,
Lender's Name �� �� �' � �
Z �, 5S PERMIT.ISSUINGFEE 6 . _
Lender's Address � �
I certify�hat I have read Ihis applimlion and sfate hof Ih �TOTAL FEE S �
above information is mrrect.I agree to comply with oll Covnty
ordinances and Sto�e laws regulating E�ectrical wiring, ond _
ereby authorize reprezentatives of fhis CouNy to eMer upon � -
bove-mentioned pr er�y for inspeuian purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE
i
$fgno ure of Permittee - Da�e
I✓
� � � . . aaPROVALS DATE � � �� � OWNER-BUIL�ER DECLARATION
� � SIGNATURE •
� - TEMP.POW.R POIE I horoby affirm that I om exempt from thc,Comioctcr's
,/�� licensa lpw for �ho iollowing reoson (Sacllon 70JI.5,
7�rEJl's`. � UNOERSLABWORK� 3�� �K, (t� �r, ��"—/� BvslnessandPtofesslonsCode):Anycl�yorcovnrywhich
� roqWres apermlf fo consfrutl,altcr,improve.demollsh.
. ROUGH CON�UIT � or rvpotr any strudurq prlor fo Ifs issuanco, also rc�
' '. � � , YJIRING quires fhe eppllcanf forsueh parmit�o ftle a slgnedslafo-
� . ' � . � men�fhat he 7s(icansedpursuant fo!ho provls(ans of fhc
' fIXTURES � Coniratfor's Llcense!aw(Chap�er 9(commentlnq wlth
� � POWER AUTHORIZED Secflon 7000)of Olvislon 3 of fhe Buslness and Proles-
slons Code)or iho�he fs exempt Iherofram ond the basls
��� � -� � UTILITY CO.NOTIFIED ' . /or 1he alleged oxompf(on. Any violaHon of Sectlon
FINAL Gn(e�on.}rorsf . _ 703I.5 by any opp(Icant for a permlt subjec/s fho appli�
canf�o a clvlf penalfy of nof moro Ihan five hundrod
� NOTES � dolfars(5500).: -
, � � � � - � ❑1,as owner of tho property will do the work,and
� � tho structuro Is nof intended or offered for sale.
. . � .� - � (Soc.704�,Buslness andProfesslons Code: Tho Confroc- ,
- � tor's Llcense Law does not appfy lo an owner oI property
� . � � � . . � � . who 6ullds or Improves fhereon, and who does such
' � � � work htmsel�provided ihat such improvemen�s ara nof ;
��-� , �� lntendedorofferodforsalc.If.howevcr,fhe6ulldfngor .
� � lmprovemont Is sofd wBfi(n ono ycar af complaflon,Ihc �
, . � , � ownar6�llderwllf have fho bu�den oI proving fhat he did
" � nof build or Improve lo'r 1he pvrposo o(sale.) .
1 am exempt under Sec. ,
8 8 P.C.for this reason �
�ate
t Owner
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