HomeMy WebLinkAbout1448A • WORKERS'COMPENSATIONDECLARATION 78A663 10/Bt qppLICATION FOR ELECTRICAL PERMIT y I
I hereby a�fhm that I h2ve 2 certificate ol conseM to sclF insure, CE-soeG
a a certificate o1 workers'Compensatbn Insurance,or a certilied NT LOS ANGE BUILDING AND SAFETY Lj
co y t of(,�e;.��O.Lab.C.) 9
. �� � COmpBny iOH APPLICANT TO FILL IN . J00 J
�' � New Residential Btdgs.8 Pools ADOnESS
❑ Certified copy is here furnished. EACH NO. FEE
1&2-Famil S — S LOCALRY
- �Certified copy is filed�with the county builtlirg inspection y,Sq.Ft. - _ '
d I� nt. i� 6lulti-tamily Sq.FL �1 �o� NEAREST .
��v+� Residential Swimming Pools CROSS S7.
Date Applicant s-� ow���oR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:F7ecsF—Light_L Sw..�lz_ MAi NAME
COMPENSATION INSURANCE ��S rS ./( ADDRESS
(Thla sectbn need not be completed if the work Involved by the )(� , First 20
Total No. `V Addilional CIT Tet.N
�permit is lor one hundred dottars(5100)or less.) .
I certify ihat in the perfofmanCe o1 the work(or whiCh ihig permit PtAN GF+ECK
is issued,I shall not employ any�person in arry manner so as to APFLICAN7 —
become subject lo ihe Wakers'Compensation Laws. l'ghtirg Fixtures First 20 � S ADDRESS
�� r Additional
� �� Total No._a� CITY Tel.No.
Date Applicant Fixed Appliznces Not Over 1 HP .
' NOTICE TO APPLICANT: II, after mzking this Certilicate ot PER'Mii
Exemption,you Shouid beCome SubjeCt t0 the Workers'Compensalion Range_ Heater_ D.W. _ pPRICANT
provisions ol ihe L�hor CoAe,you must lorthwilh comply with such Oven_ Dryer_ YJ.M._ � A��RES �l
provisions or this permit shall be deemed revoked. 7op _ FAU _ NlH._ GIT Tel.N
LICENSED CONTRACTORS DECLARATION Hood_ Fan _ Other_
I hereby affrm that I am licensed under provisions of Chapter 9 uCEN E oR
(commencing with Section 7000)ot Division 3 of the Bus�ness and DiSp. —ROOrtI Ai(CAf1d. _ REG.NU�ABER . CL]5. �
Professions Code,and my license is in fu!I torce and effect. o�SraiC7 NO. � aaOCESSEo ev
I Power Apparatus 8 Large Appiiances 1 �'•,.
r {�'�(� ���(� Size&Type HP,KW,KVA,or KVAR v LL
� License Num6er�1 W 7'1� Lic.Class>._LL� Up to 1 Incl. �� PINAL �
Over 1 to 10 Incl. DATE yp��DATION O
Contr2dor�� Da�e� Over�10 to 50 Incl. / U
FINAL
❑ 1 am erempt untler Sec. � Over 50 to 100Inc. gy �
68P.C.for this reason Over 100 N
Services,Swbd..MCC 8 Parielboards � �� � � �� Z
Daie� 0-200 Amp.Under 6D0 V
� Signalurc 201-1000 Artra.Under 600 V - �
- � � - Over 1000 Amp.or Over 600 V
❑ Exemption for Feg.Maint Eted. . . ... . ,. . . . . .. .
SINGLE FAMILY Temp.Power Poie 8 ApWrtenances
HOME OVJNER•BUILDER DECLARATION � Sign with One Brarh Gircuit � � �
1 hereby alfirm that 1 am exempt(rom the Con!ractor's License law �
`or t7z{o'awing rza;on(Szctlon 7C31.5.Cusiness and Prc`assions Nitlitional Sign 6ranch Circuits ;, �� U n
Code):
Misc.Condui!s 8 Conductors �• • • ° '2 �
❑ I,2s owner of the property,will do the work and[he structure �
is rwl in!ended or oflered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ �
and Professions Code). . ' " � � °��a� �
CONSTRUCT�ON LENDING AGENCY - � " o C Q O.� O�
I hereby alfirm lhat there is a conslruction lending agency for[he
performance af[he urork fo�which Ihis permit is issued(Sec.3097, pERM1T FEE (Sub-Totap 2 . �9.�P—b�
Civ.CJ.
. PLAN CHECKING FEE . .
Lendcr's N�me /
PERMIT ISSUING FEE _. [O _
Lender's Address
1 certify that 1 have reed this aDPl�cation and state Ihat lhe above TOTAL FEE �y0,�U
information is correct.1 a9ree to comply with atl Coun.y ordinances �
and Stat=Isws regula!ing Electrical wiring,and hereby authorize ' -
representatives o1 this County to en!er upon the above-mentioned -- � - �
property for Inspe M , irpases.
�\(9,�R �9 p(y SEE REVERSE FOR EXPLANATORY LANGUAGE
r DJ V 1�7�l�b
qnature of Permiuec� Date
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