HomeMy WebLinkAbout1417A WORKERS'COMPENSATIONDECIARATION � 76Ad63 �o,a� qpp��CATION FOR ELECTRICAL PERMIT �
I hereby affirm that I hove a certificate of.consen� self �E-806G
insu�e,or o certificate of Workers'Compensarion rance, COUNTY OF LOS ANGELES BUILOING AND SAFETY
or a cedified copy thereoi(Sec.3800,Lab.C.
a�Y Company � FOR APPLICANT TO Flll IN JOB
Certified co ereb ished. _ . New Residemiol Bidgs.&Pools EACH NO. FEE.
ADORES$ 3 V
� Cerlified co ded wi oN 6uilding inspec- 1 8 2-Family,Sq.Ft. � — S LOCALITY �y
tion d ent. Multi-family Sq.Ft. � — NEaaEST
ResideMiol Swimming Pools CROSS ST. h �
D Appliconl , OwnIER OR ' Z
FIRM NAME
� CERTIFICATE OF EXEMPTION FROM WOR ERS Outlels:Rec�Light_Sw.� ��� � •
COMPENSATiON INSURANCE � � ADORESS � •
(Thlt�eetlon naed nof 6�complet�d if fh�work fnvolved by First 20
Ihv parmif Is Ior one hundred dollars(SI00)er la��.) Total No. � Addirionol CIiY p Tel.No. �
I certify lhot in fhe performance of the work for which ihis . PLAN CHECK
erm�t�s issued,I shall not em lo an /PP�ICANT - �
P p y y pers n in any manner �� htin Fixtures First 20
o as to bec(o�me s�Cbject to ihe W s' ion Laws. 9 9 ADDRE55
�Date � "�"� a Total No. Additional
CITY Tel.No.
pplicant Fi.ed Appliances Nol Over 1 HP
NOTICE TO APPUCANT: If, ofter a mg is Ce� ka of PERnniT
Ezempiion, you should become subject to the r ers' Range_Heater_D.W._ nvaliGaNT (�..�, � (,
Compensation provisions of the labor Code;you must(orth- Oven =Dryer _W.M._ ADDRE55 � `�' W -
with tomply with zuch proviSions or ihis permit shall be
deemed revoked. Top ^ � —W.H.— , CIN �� � 7e1.No. ��4
� LICENSED CONTRACTORS DECLARATION Hood�.L Fpn _Other_ �
�Disp.t�Oom Air Cond. — LICENSE OR Class.� O
I hereby affi�m ihm 1 am licensed onder provisions of Chap�er 9 � REG.NVMBER d Z -
(commencing wilh Section 7000)of�ivision 3 of Ihe 8usiness powerApporotus 8 Large Appliontes DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and eifect. � .�O a
��Size;TYp'e HP,KW,KVA,or KVAR' Q
License Nvmber�_Lic Class�� ' Up l0 1 Ind. � FINAL / � . . . V
r�-�� 1� DATE �t
�] �� Over 1 lo 101nc1. ✓ VALIDATION � �
.Contracror - Date •� O�er 10 to 50 Incl. �,,,
� FINAI
�I am eKempt under Set. Over 50 to 100 Inc. . BY W
B.SP.C.for fhis reason Over 100 d
N
. pa�e. -. Services,Swbd.,MCC 8 Panelboards � � , . . . �
0-200 Amp.Under 600 V
Signa�ure - 201-1000 Amp.Under 600 V � � � .. . �
❑ Over 1000 Amp.or Over 60p V
Ezemption for Reg.Maint,Elect. �
SINGIE FAMILY . Temp.Power Pole 8 Apporfenonces �� 4�,7 A
HOME OWNER-BUILDER DECLARATION S�gn wi�h One Branch Circuil �- ' '
1 hereby offirm�hoi I am exempt from the Con�mdor's license� �� • . •�•2 �
Law for the followinq.eason(Section 7031.5,Business and Additional Sign Branch Circuils , �
ProFessions Code): . ' I • �'Z'T 5 Q
� Misc.Conduiis 8 Conductors � . , .
I,as owner of ihe property,will do�he work ond rhe �� • •L�,�O�
shvcture is nm intended w oi(ered for sale�Section Oiher(See Complefe Fee Schedule)_ , . �
7044,Business and Professions Code�. Q 7�� 8�8 5
CONSTRUCTION LENDING AGENCY . ,.
I hcreby ai(irm ihat there is a mnsiroUion lending ogency for - �
' �he performonce of the work ior.which�his permit is issued - PERM�T FEE � � - � (Sub-To�al�
�Sec 3097,Civ.C.�. . . .... .. . . . - '
PLAN CHECKING FEE � �� �
Lender i Name � - - '
PERMIi ISSUING FEE . �C�
Lender's Address � � - �
I cerfify tha�I have read�his applim�ion and state�ha�the T�TA�FEE •
obove in(ormation is mrred.I agree to comply with oll County -
ordinonces and Stafe lows regolating Elettrical wi�ing,and �
hereby authorize rep�esentalives of Ihis Counfy to enler upon � � ' " � - - � � �
e abo -me 'oned erty for inspection purpozes. SEE REVERSE FOR EXPLANATORY LANGUAGE
`ti-I$—�bS
ignat e of Per tt Date � � .
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