HomeMy WebLinkAbout10-0006 5695A (7)WORKERS'CQMPENSA'f10N DECLARATION
APPLICATION FOR
ELECTRICAL PERMIT
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A06
CF 8013G (2-80)
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1 hereby affirm that I have a certificate of consent to self
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
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Insure, or a certificate of Workers' Cenupensation Insurance, or
a certified copy thereof (Sec. 3900, Lab. C:.) ' F
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FOR APPLICANT TO FILL IN
�E�n'�a'�r�{i
JOB ,sf T��Q�y
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Policy No. Company ✓7�°'Y j
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New Residential Bldgs. &Pools EACH NO. FEE
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Certified copy_ is hereby. furnished.
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1&2-Family;Sq. Ft. $ — $
LOCALITY l
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Multi -family Sq. Ft. —
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Certified copy Is filed with the county building ," s
Residential Swimming PoolsCROSS
OWNER
department. ';
FIRM NAMJ�6r�'�yC/x
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llate �'� ApplicentA/--0 E 4/';r4 \"""'< •:9
Outlets: Rec.—Light_Sw._
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MAIADDRESS P'r�%%B,S�N_!l �f'
CLRTIFICATE OF EXEMPTION FROM WORKERS'
First 20
Total No. Additional
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CITY Tel No. J CV4i
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COMPENSATION INSURANCE
PLAN CHECK
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APPLICANT
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(This section need not be completed if the work involved = Lighting Fixtures First 20
ADDRESS
by the permit is for one hundred dollars ($100) or less.) #
Additional
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Total No.
CITY Tel No.
1 certify that in the performance of the work for which this :':'-
Fixed Appliances Not Over 1 HP
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. permit is issued, I shall not employ any person in any manner '_
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PERMIT /,�
APPLICANTT/#VF-__r�p1r S'% '
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ao as tD become subject to the Workers' Compensation Laws. .,
Range_ Heater_D.W. _
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Oven —Dryer _ W.M. _
ADDRES ,�++
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Date Applicant
Top __FAU _W.H.,_.
_L'SG•r�i�t"
CITY •-'��gph� Tel No.3 +Q��'
,NOTICE TO APPLICANT: if. after making this Certificate of
Hood _ Fan —Other
Disp. Room Air Cond.—
LICENSE OR -s# ��y -
REG. NUMBS ' �C Class
:Exemption, you should become subject to the Workers'
'Compensation provisions of the Labor Code, you must forth-
:Power Apparatus & Large Appliances
DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit sball be
:, Size &Type HP, KW, KVA, or KVA
1
deemed revoked.
Up to 1 Incl.
FINAL }
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 um licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect,
License Number'a Class
HOME OWNER -RSI N�,l',S ECLARATION
I hereby affirm that 1 am exempt from the Contractor's
License Law for the f.11 -wing re___^ (Section 703!.5, Bus,
ness and Professions Code). -
. 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONS'T'RUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance sof the work for which this permit is
issued (Sec. 3097, Civ. C,).
- Lender's Name
Lender's Address
Over 1 to 10 Incl.
't
Over 1'0 to 50 Incl.
Over 50 to 100 Inc.
Over 100
)Services
0.200 Amp_, Under 600 V
201.1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
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Temp. Power Pole & Appurtenances
ign with One Branch Circuit
Additional Sign Branch Circuits
._ Misc. Conduits & Conductors
_Other (See Complete Fee Schedule)—
PERMIT FEE (Sub -Total)
PLAN CHECKING FEE (One -Fourth Permit Feel
PERMIT ISSUING FEE
DATE X0/5/ VALIDATION
FINAL 1
13Y
icy - moca b
Fa569,5A
• a a o d C
aO to °2050
1 certify that I have r ad this application and state that the ' TOTAL FEE - _-
above information is rrect. I agree to comply with all County • a ° 2 0..5 0 <.:
ordinances and St. a laws regulating Electrical wiring, and
hereby Guth ze ntativea of this County to enter upon C R, C-4 — 5 1
the above- o ed pro rty for inspection purposes. sr:x REVERSE FOR EXPLANATORY LANGUAGE
Signature o ittee Date
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