HomeMy WebLinkAbout1451A WORKERS'COMPENSATION DECLARATIDN 76A663 10/81 � � � �� � � � � � ��� �� � � � -�� � � �
. . . _ .. ..... �
I hereby affirm fhot I have a certificate of consent ro self CE-806G A�PPLICATrON FOR ELECTRICAL�PERMIT -
insure,or a certificme of Workers'Compensatiori Ins�rance. COUNTY OF LO$ANGELE$ BUILDING AND SAFETY
or a e c p�yf�(tfhereoff.�(Se�c.3600,L�ab.C.l
Palic o.l �`"�S Z'pmppny �""" FOR APPLICANT TO FlL41N J08 �]�[J �"� /�
� EACH NO. FEE ADDRESS��// // Q,�J-x/ L?I��_
Certified copy is hereby furnished. New Residential Bldgs.E Poo�s
� � 1 8 2-Famil q. LOCALIN
Ceriified copy is filed with ihe o�my building inspec- y,S Ft $ — $ /T Q
NEAREST
�ion d� � Multi-fomily Sq.Ft. CROSS ST. ♦
Resideniial Swimming Pools OWNER OR �n',�- e� ��
D e Applicani FIRMNAME l�,`� TG/74'
CERTIFfCATE OF EXElvIPTiO?J FROM WORKERS'� MAIL /n I / ` � p�
Oodeis:Rec_Light_Sw._ �
� - COMPENSATION�INSUhANCE� �- n�oeess /o� N
(This sec4ion naed noT be complefed if the�work Involved 6y First 20 .
Total No. Additionol CITY � r.��, Tel.No.
the parmit is For one hundred dollars(SI00)or less.) pwrv CHECK�
I ceriify ihal In the performonce of the wark for which this APPLICAN7
permif is issued,I shall noY employ any person in any manner
so as to becom�subject to rhe Workers'Campensation Laws. �ighting Fixt�res First 20 ADORESS � �O ��t,j� �
� � � � - ' ' To�ai No. Additional � 2 3
� Date Appliwnt CITY � � I.No, .�b,g��
�NOTICE TO APPLICANT: If, ofter making ihis Certificate of Fixed Applipnces Not Over 1 HP PERMI7 �
Exemption, you should become subject to the Workers' Range_Heater_D.W. _ APPUCANT
Compensation provisions of+he Labor Code,you must forih- Oven _Dryer —W.M.— A�DRE55
with comply wilh such provis�ons or this permit sholl be Top —FAU —W.H._
deemed revoked. Hood _Fan _Oiher_ CITY Tei.No.
LICENSED CONTRACTORS DECLARATION LICENSE OR '
I hereby affirm�ihot I om licensed under provisions of ChopteF 9� Disp. _Room Air Cond. — REG.NUMBER Class.
(commencing wifh Section 7000)�of Division 3 af fhe Business power Apporalus 8 Large Appliances DISTRICT NO. PROCE$$E BY r
and Professions Code,and my license is in full force and effect. a
��/t� �" 6/,� Size&Type HP,KW,KVA,�or KVAR ��
License Numbe`^�'-'�- Li<.Class `�� Up to I Incl. o
��j� .r� FINAL
Contracror/'�T+�j�")� are ����°�� ��er 1 to 10 Ind. �ATE � .� f� VALIDATION o
O � . . � Over lO to 50 ind. ��� V
FINAL
I am exempt under Sec. Over 50 to 100 Inc BY � ua
, . . Over 100 'j V'C. {��-"iZ's's-'---- O'
B,&P.C.for this reason �
� - ._.. .. _ .. . Services,Swbd.,MCC 8 Panelboards ► �
Date:� 0-200 Amp.Under 600 V
Signatore � 201 -1000 Amp.Under 600 V
O - � Over 1000 Amp.or Over 60D V
Exempfion for Reg.Maini.Eled.
� � SINGLE FAMILY �� Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Bronch Circuit � a
I hereby affirm rhot I om exempt from 1he�Conlrocinr's�License� qdditionol$ign Branch Circuits
Law for the following reason(Section 7031.5, B�siness and
Professions Code):
❑ I,os owner of the property,will do the work and the Misc Conduits&Cond�ctors
. siructure is not inlended or offered for sole (Se<tion Other(See Complete Fee Schedule}_ ► z� oy�j,� A
7044,Business and Professions Code). �
CONSTRUCTION LENDING AGENCY �`o e. a�
1 hereby offirm ihai there is a construction lending ogency tor . j m o%j,5 Q
the performance of ihe work for which this permif is issued PERMIT FEE (Sub-Totol�
(Sec 3097,Cio.C.1. - e o o j F�(�_
U
PLAN CHECKINC,FEE ��y L
Lender's Name Q 2��i'��l
� . PERMIT ISSUING FEE , - q^ �
Lender's Address
I certify thal I have read ihis applimtion and state ihat the TOTAL FEE
above informo�ion is correct.I agree to comply with all County
ordi ances nd Stafe I s uloting Elenriml wiring, ❑nd
her y o h rize repr s t' es of this County to enter�pon
the bov - e� ty for inspe<tion purposes. �
���� SEE REVERSE FOR EXPLAkATORY LANGUAGE
V
SignoWre of Pe�mittee Dafe
�
' �..,-.-.,.,�,�a_. . _'__-.-.:a-rm. _".. � ..__.� . . _. _.
. .>.,._-..«....�-..-:-.., _ -�.-�-�-=-'`:- .
.� � � � - - APPROVALS oAie. .� � � . . .� ... . . � .. . . OWNER-BUILDER DE�LARAT!ON
. . - I SIGhA7URE
� � _ � TEMP.POWER POLF I � � I hereby offirm that I om exempt 4rom the Coniracic�s
Licanse Lnw tor ih� following r�ason (Soction 7031.5,
UNbERSIAB WORK � Susiness dnd Professlons Code):My ci;y or cour,fy v✓hich
� ROUGH CONDUIT � requires a permN to rnnstroci,af4�r,improve,demott;h,
- � � .. � � o�reoa7r any s!rotture,prior to i!s issucrce, also re-
.._ , . . . _.. . ..
. . WIRING � qulras fbe opplimnf fo��soeh pa�ml44o filc o signed sfo9e-
manro that 5e!s Ficansed pursuant to tha provtcions of ine
PIXTURES - Conlrocior's License Law(Cncpfer 9(tommancing with
� � � WJWER AUTHORIZED `_� Seciion 7600)of Divisi�n 3 of tbe 8usiness and Profes-
� - - sions Code)or thaf he"rs exempi ynerefrom and tbe basis
� � - � UTILITY CO.NOTIPIED � for fhe alleged exemption. Ar,y vioiaJicn of Sectior
- FINAL 7031.5 by any app[icanP for a parmit suu(ects fhe opp!i-
� .. _ . � . . c7-- .
� �ron1 - eo{rt to�ci_,if penalty of not more fben`ive hundred
nfaa mia
' - . ..- � . .. ... .. .... :._�,....:.:.�.,.._...,a.K,.,�:�.M...�.x_u,:.,.xi.....�...,.
. � . . -'NOTES� ' � � . . . . _ ,.�a . �- "�ollars( `O�j.:
. ❑I,as owner n4 th�properfy wili cio ihe work,and
-� "� - the siructure is not intended or offered ior sale.
._..._,.................._..,........,......_.._-........._....__.._,_._.,..r....:..T-_,,,r,a✓-::c::'-r,��:m:mce.r:,�.�:.:::y,c»cs.µ::��:......� _....__.
- r5ec.70%A;$aslness ond Professlons Code: Ph�e Conirac-
. � tor's License Lavs doas nof appfy ta an owr4r of properfy
. . . . .............-..._... .. .,_._............... ...,..:._._..b,H_�.w--•.......wme�.a�,.a..�o-�....:,,.,x.�,w..�,..�.a._..:,..�
_ .. . . . ___. . Vvho buNds or(mproves thereon, and who does such
work bimsalf provided thot sucb�mprovomar.is ore not
.._.. .. ._...,...a......�_.,.,.�.r_..__.....�-._,...::....:...:.....::::.:�—.�w,v..:.;.,:w:.,:�..�«ssuxa:.-.;;:-wa�:;.m�z.„-rn-:.�-.s:<_�.sxs¢�cu:.rse:-,InI'endrd or o3fered for safe.(f,howover,Ltia buildir,g or
� � �� improvemanP is sold wttliin one year of mmplefion,tha
� � ��� ������������'��""""`"���'�""�""��'�"'"��'�""�"`"�"'�""d"��'6�LGher-bWfder wifl have the burden of nroving tbai;�a did
� ._ ' �� noE build or improve for iha purpose ot sa[e J
. . . . .._ :.... .. .. .....::. ...:....�..r.�er�w:.y m.ce�.,:,.,.-._•:.Y, ,r.s�wo�^,,,m:,m.,.^-�rx.�.xc'.r�<e�,ok.x�,Y..:.,.m....»..,..u,..�.._.s..-c.se,.e.n ._..
. . n�,.. .,...,..,
. •. " � ... � . I am exempt under Sec. ,
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. . . .. _...� --. ..,.-.,.:-.�,,..:.,.�_..,,.,...,-� �— . B&P.C.for this reason_
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. . . . . ._ .... . .. .
... - Dase ._ .. .... ..._...�_..
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Owner
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