HomeMy WebLinkAbout1824A (21) WORKERS'COMPENSATIONDECIARAT�ON 76A667 ,o,e� . APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affirm �hot I have a cer�ificate of consent to self CE-so6G
insu�e,or a certifkote of Wo�ke�s'Compensmion Insurance, , COUNTY OF l05 ANGELES - BUILDING AND SAfETY
or a cer�i(ied copy fhereof�Sec.3800,Lab.C.)
P❑olicy No. Compony fOR A►YLICANT TO Flll IN JOB 6S3 . � �
Cerfified copy is hereby furnished. EACH NO. FEE�" ADDRESS O
New Residentiol Bldgs.8 Pools � .
� Certified topy is filed with the co�nly building inspeo 1 8 2-Fomily,Sq.FI. S — S IOCAIIN .Rj,
flon deporiment, Multi•fomily Sq.F1.,�� . = O NEAREST
Residenliol5wimmingPools . O O CROS55T.
Date Applicanf . OWNER OR
��y FIRM NAME
� CERTIFICATE OF EXEMPTION FROM WORKFRS' Outlets:Rec�ight�{/�w.O ��� ./
�' �COMPENSATION INSURANCE ADORESS V L
` Q,�,�.. First 20 O O
(ThI��sc}len n��d nof b�completed iF tha work fnvolved by Total No�p�su� Additional ee ��TM Tel.No. � a
fh�p�rmif is for ona hundr�d dollan(f10D)or I��s.)
I cerlify Ihat in 1he per{ormance of the work(or which lhis PLAN CHEC a '
APP�ICANT
permit is issued,1 sholl no1 employ any person in any manner r C �
so as�o become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ' �V � ADDRESS ��
_ Toral No.}� Addi�ionol �
CITY
Dole. epPlicont Fixed Applia�nces Not Over 1 HP PERMiT '
NOTICE TO APPLICANT: If, after making Ihis Certiiitale o( �g APPtICAM
E�emp�ion, you should bemme subject fo the Workers' Range_llNieater_D.W._ .
Compr.nsation provisions of ihe Lobor Code,you musl forth- Oven _Dryer _W.M._ ADDRE$$
with comply with s�ch provisions or this permil shall be Top _FAU ._W.H.—
deemed revoked. Hood _Fan _Other_ ��TY iel.No.
LICENSED CONTRACTOR$DECIARATION �7 Q D LICENSE OR
Ois _Room Air Cond. —�7�0 � V Class.
I he�eby offiim ihat I am licensed under provisions of Chapter 9 P' aEG.NUMBER -
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY
ond Professions Code,and my licensa is in full force and effecc Power ApparaNs 8 large Appliances - �` 0�..'
- Size 8 Type HP,KW,KVA,ar KVAR� t� V
License Number Lic.Closs Up to 1 Incl. FINAL �
Over 1 to 10 Incl. DATE
VALIDATION
Controcror Dale U
OOver 10 to 50 Incl. FINAL W
I am exempt under Sec. Over 50�0 100 Inc. By p��
8.8P.C.fo��his reasan Over 100 �
Dore: � Services,Swbd.,MCC 8 Panelboards a � —
0-�00 Amp.Under 600 V O e
Signature 201-1000 Amp.Under 600 V A � � �
OOver lODO Amp.or Over 600 V �1 �,�4 a
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole 8 Appurtenances '�t• •��i � g
HOME OWNER-BUILDER DECIARATION Sign with One Bronch C�rt�it
I hereby affirm thol I am ezemp�irom the Conhacfor i litense � �e b.Ti 4 17 U
I Law for ihe following reoson(Section 7031.5, Business and Additional Sign Branch Cirtuits �
Professions Code�: •��J�O O=
� � Misc.Conduirs 8 Condudors . �
I,as owner o(the property,will do Ihe wo�k and fhe
struc�ure is not intended or offered for sole (Sedion er(See Comp�e�e Fee Schedule�_ , 0 Q�9�8(� .
7044,Businezs and Prolessions Code). ��L� �. D
CONSTRUCTION IENDING AGENCY �
I hereby affirm�ha��here is a tonstruc�ion lending agency for �
the perlormance of the work for which Ihi3 permit is issued PERMIT FEE � (Sub-Tolal) � �
(Sec.3097,Civ.C.). �
PLAN CHECKING FEE � '
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I cer�ify ihai I have reod this application and s�aie Ihat the TOTAL fEE
above in(ormotion is correc�.I agree 10 comply with all County
ordinances and State laws regulating Electrical wiring,and �
hereby authorize represenlolives oi Ihis County 10 enter upon - �
the obove-mentioned property for�nspection purposes. SEE REYERSF FOR EXPLANATORY IANGUAGE
Signa�ure ef Germinee Do�e .
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