HomeMy WebLinkAbout1107A (9) � _,
WORKERS'COMPENSATIONDECLARATION � 76a863 APPLICATION ,.F,�._, .ELECTRICAL PERMIT � �
CE$O6G(2.80)
'1 hereby ur�irm that � t�ave a ceniticate ot consent to selt COUNTY OF LOS ANGELES BUILDING AND SAFETY
insuro,�or a rertiticate ot Workers'Compensation Insurance,or _ " � . '
a certified copy ihereof(Sec.3800/,Lab.CJ /� -%� '� '
�Pulicy No���"Company?ee�JV� ��''^��� FOR APPLICANT TO FILL IN ' qDORE55 QO ,�J �
� , New ReSidential B1d95.&PoolS EACH NO. FEE �
� Certified copy is hereby furnished. 1&2-Family,Sq.Ft. � $ —'" s � LOCALITY
�—�/ Multi-family Sq.Ft. � �
�}—�ertified copy it filed with the county building insp tion CROSS ST �d'
� department. � Residential Swimminq Poats �, OWNER OR
_� •� �/H//�� ' FIHMNAME C •
Date Applicant�r��'" • ��rn ��� � Outlets:Rec._L�ght_Sw._ � � MAIL
Firs[20 � F10DHES5
CERTIFICATE OF 6XEMPTION FROM WORKtiRS' Total No. Additional � CITY ' Tel No.�[rs'(' , }
� - COMPENSATIONINSURANCE . � � � . PLaN cHECK a
(7'his section need not be completed if the work InvOl�ed � - APPLICANT � �
U
Lighting Fixtures � First 20 AOORESS
by Ihe permit is tor one hundred dollars(SI00)oc leas.) �t
. Addi[ional
1 certify that in[he performance ot the work fur which this F xed Appliances Not Over 1 HP � � CITv Tei No. �
permit'u issued.1 shall n�t employ any person in any manner pERMIT W
so as lu become subject to�the Workers'Compensation Laws. Range_Heater D.W._ APPIICANT G a
� � ' � . Oven �Dryer_W.M._ AODRE55 Q , � N
. . Top _FAU _W.H.._ ' z
Date Applicant Hood_Fan _Other_ � ��TY ��y Tel No. - � Z7
�OT10E TO AYYLICANT:-If,after making this Certificate of Oisp. _Room Air Cond._ LIC NS OH �
:zemption, yo� should become subject ro the Workers' REG.NUMBE Class
'ompensation provisions of the Labur Code,you must forth- � power Apparotus&Large Appliances DISTRICT NO. PROCESSED 8Y
rith comply with such provuions or this permit shall be Size&�Type HP,KW,KVA,or KVA �
eemed cevoked. � Q
. Up to 1 Incl. � FINAL
Over 1 to t0lncl. oq7E /a L VA�IDATION
LICGNSED CONTRACTORS DECLARATION � Over 10 to 50 1ncl, `��/d� . . �
zreby aFfirm that 1 um licenseJ under provisions of Chepler Over 50 to 700 Inc. - BINAL ' .
'commencing with Sectiup 7000)of Division 3 of ihe Busi- Over 100
•��and Ymfessium.Code,and my license is in full fotce and � � ' - �'� .-
��• �j ' p ' Services � �
.icense NumbEr��3U� Lia Class (-��Q 0-200 Amp.Under 600 V
�/'/ /� 201•1000 Amp.Under 600 V �
Cuntraciof��n/ t ���/�¢T¢ ��••,� ?'� Over 1000 Amp.or Over 600 V � • .
HOME OWNER•BUILUER DECLARpTION 7emp.Power Pole&Appurienances � -
hereby atf'um that I am exempt from the Con[ractor's Sign with One Branch Circuit � . � - �
.icense Law for the�foliowing reason (Section 7031.5,Busi• - Additional Sign Branch Circuits . . z°�.� Q 7 A
,ess and Nrofessions Code): � � . �
� Misc.Coaduits&Conductors #• • • • �2
� I,as owner of the property,will do the work and the pther ISee Complete Fee Scbedule)— � �
structure is not intended or ofPored for sale (Section � • •2 Q Jr.o -
7044,Business and Yrufessions Code).
CONSTRUCTION LENDING ACENCY . •� � �2 Q S O u� -
hereby affirm that there is a cunsirUction lending agency
or the pecformance uf the work for which this permit is pERMIT FEE � � (Sub•Total) � . I 2 P S�S.� -
��sued(Sec.3097,Civ.C.). � �
.endePs Na��n � PLAN CHECKING FEE IOne-Fourth Permit Fee) � �
enJer's Address PERMIT ISSUING FEE ' � S�
certify that 1 have read this application and state that Ihn TOTAL FEE � , � . , ' ' -
wve information is correct.I agree lo comply�vith all County . . . .
rdinanres and State�Inws regulatfng Electrical a�iring, and
:reby authuriz�representatives of this Counly to enter upun , . � - .
b v entio i ro erty for inspection purposes. � . SEE'RLVERSE FOR LRPLANATORV LANGUAGB � �
Signature of Yermittee Da� �
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