HomeMy WebLinkAbout1346A (11) WORKERS'COMPENSATIONDECLARATION � 76A663 ,o,e, APPLICATION FOR ELECTRICAL PERMIT �
I hereby afiirm Ihat I have a tertificate of consenr ro self CE-e06G
insure,or a certiiicaie af Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cerfified mpy thereof�Sec.3800,lab.C.) � � . -
P❑olfcy No. Company fOR AP►LICAM TO FILI IN JOB
Cerlified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ADDRE55 1
� 1 8 2-Famil Ft. s — S �OCALITY
Certified copy is filed wiih the coun�y b�ilding inspec- Y�S9•
lion department. - Multi-family Sq.FL CR0.5SSST.
Resldential$wimming Pools OWNER OR '
Date Applicant . . �-� . .. . . ' . FlRbn NAME /
CERTIFICA7E OF EXEMPTION FROM WORKERS' Outlets:Raca�Light�Sw.J^- ���
� COMPENSATION INSURANCE p� ADDRE55
Firsl 20
(Thi�s�cHon nMd not bs completed II fh�work invoH�d by Total No.� Addiiional GY�CITY . . Tei.No.
�ha p�rmif is For ons hundred dollors(5100)or lo�a.)
I cerlify Ihol In Ihe performance of the work for which Ihis PL.CNCNECK .
APPLICANT
permit is issued,I shall no�employ any persan in any manner • ,
so os�o bemme subjetl to ihe Worker mpensa�io a s. Lighting Fixtures First 20 ADDRE55 -
Totol No.�� Additionul CIiY Tel.No.
Date�`�"A� ApplicaM� Fi.ed Applionces Nor Over 1 HP pEprv,iT
N0710E TO APPLICANT: If, ofter moking �his ertif'r ate of qpptlCnNT , � 'f G
Exempiion, you should 6ecome s�bject to the Workers' Range_Heoter_D.W._ �
Compensation provisions of the Labor Code,you musl forlh- Ovan —Dryer-_W.M._ � ADDRE55 �.�7f �TyO✓Th� l:/G
wi�h camply ith such provisions or this permit sholl be Top _FAU —W.H.2� . CITY ���-� Tel.tJo.�/9 8s7;8 .
deemed revoked. � Hood _Fon _Other_
UCENSED CONTRACTORS DECLARATION pp uCENSE OR �6 G S�Z C I�
I he�e6y aHirm that I am licensed unde�provisions of Chap�er9� Disp. _Room Air Cond. — REG.NV/�BER Class.
(tommencing with Section 7000)of Division 3 of rhe Business power Apparat�s 8 La�ge Appliances DISiRICT NO. PROCESSED BY �,
and Professions Code,and my license is in futl iorce and eHecL � � � " �' � d '
Size 8 Type HP,KW,KVA,or KVAR� O .c/ �
license Numher 3G6542 Lic Class ��� � U tol Incl. DATE� �� j p �
Over 1 to 10 Ind. . ,_(�'(1 J� VALIDATION Q �
Conimclor._,��5 /-t'e'17/GDafe �'�'�g � Over 10 fo SO lnd. FINAL � W '.
❑ I am exempf under Set. Over 50�0 100 In[. BY ��\j�`C�((,U,l�t_- � - p.
Over 100 '�
8.8P.C.for this reason � Z
�� Date: � SerJices,Swbd.,MCC B Panelboords � � � � � -"-
0-200 Amp.Undar 600 V
5gnature � 201-1000 Amp.Under 600 V . . . � " �� 3 fj 6 p
a . Over 1000 Amp.or Over 600 V
Exemption for Reg.Moinl.Elect. #i � • •�+'�
SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER-6UILDER DECLARATION Si Ih One Bronch Circuit I • �7�1 J�O .
I here6y aiiirm thal I am exempf from the Contrattor's License 9�W� '
low for the following reason(Section 7031.5,B�siness ond �+dditional Sign Eronch Circ�i!s •']�5 Q
U
Professions Code): .
❑ I,as owner of rhe praperty,will do the work and the Misc.Co�d��rs 8 Cond�dors � O 2 O�'$�
strodvre is no1 inlended or offered for sole(Section 01her(See Complete Fee$chedule)_ ,
' 704E,Business and Professions Code).
CONSTRUCTION LENDING AGENCY . � � - - - -� -
I hereby oNirm that there is a constroction lending agency for . ' t
the performante of�he work for which ihis permit is issued PERMIT FEE - (Sub-iotal) � �- � ��-
(Sec.3097,Civ.C.). � .
. � PLAN CHECKING fEE� - � - � • �� --
lender's Name � �
. PERMIT ISSUING fEE . . O D . . ... -
Lender's Address
I cerlify that I hove read this applimtion and srate that the TOTAL FEE . S(� . . . . .. . . . . .. _
above information is conecL I o9ree to comply with all County . . ,
ord' a ces and Stat aws re ulating EleUriml wiring,and � � . ,
h eb au rize r resen ii s of this CouMy fo eNer upon � � .
r e a v - en+i ed pr e� for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signoture of erm" ee ��`�Da��� J
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