HomeMy WebLinkAbout1697A (17) �lzc� /o
WORKERS'COMPENSATION DECLARATION 76A663 �o,e� � APPLICATION FOR ELECTRICAL PERMIT �� �
I here6y aNirm Ihal I hove a certificale of consenl to self CE-BO6G
insu�e,or a certificole of Workers'Compensalion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Set.3800,Lab.C.) , ,
POoi�ity No. Compony FOR AVPLICANT TO Flll IN DDRE �f
Cerli(ied copy is hereby furnished. EACH NO. FEE
New Residential Bidgs.8 Poals
� Ce�tified copy is filed wi�h�he county 6uilding inspec- 1 8 2-Family,Sq.Ft. E — 5 IOCAIITY �a
NEAREST � /
�ion depanmem. M�lii-family Sq.Ft. CRO55 5T.� �/�
Residential Swimming Pools
Date� " Applicant . OWNER OR �5
FIRM NAME
� CERTIFICATE OF EXEMPTION FROM WORKFRS' Out�ets:Rec�ight,�,Sw.� ��� � ,
� COMPENSATION INSURANCE Firit 20 � ! � ADDRES
(Thia a�cHon nwd not b�cempl�Nd ff th�werk(nrolwd by Totol No.� Addi�ional / QJ ❑ S Te b_ [�
Ih�permtf ia for on�hundrsd dollars(f100)or less.) GIAN�HECK
I certiiy tha�in the performance of the work for which�his APPIICANT
pe�mit is iss�ed,�shall not employ any person in ony monner
so as�o become su6ject to the Workers'Compensation Laws. �ighting Fi.ture/s_� Firs�20 � � ADDRESS�� �/�
To�ol No..�Q� Additionol Q��'
CITY d�J �./+�.-�,�• /g
Doie opplicant Fixed Appliontes Not Over 1 HP
NOTICE TO APPLICANT: If,�affer moking this Certifimte oi PERMiT
Ezemp�ion, you should become subjett �o the WO�kBrS' Ra�9e_Heo�er_p.W.� APPLICANT
Compenselion provisions ol�he Labor Code,you mus�for�h- Oven _Dryer _W.M.— ADDRESS
with tomply with s�ch provisions or this pe�mit sholl 6e Top _FAU _W.H._
deemed revoked. � Hood _Fan _Other_ CITY . Tel.No. .
UCENSED CONTRACTORS DECLARATION � UCENSE OR
I hereby affirm tha�I am licensed�nder provislons of Chap�er 9 �isp. _Room Air Cond. — REG.NUMBER Class.
commencin 'th Setlion 7000 of Division 3 af the Business ,. �
( 9"+' ) . . DISTRICT NO. . . PROCESSED BY .. . �...
Power Apparvluz 8 Large Appliances�
ond Professions Code,and my license is in full force and eHect. � � � � ��� � �� � O
?���ya�ef,8�Typ�HP,KW,KVA,or KVAR � �/ . U
License Number Lic.Class �L Up to 1 Ind. �� K ! DATE` 0
Contrador Date Over 1 to 10 Ind. VAUDATION U
❑ Over 10�0 50 Intl. FINAL W
I am e*empl under Sec. Over 50 to 100 Inc. BY n-
.N
8.8P.C.for this reoson �°e��� =� b�/A � Z
� Services,Swbd.,MCC 8 Panelboards y�
Dote: 0-200 Amp.Under 600 V � � � �• e • ` � 9
Signa�ure 201-1000 Amp.Under 600 V
OOver 1000 Amp.or Over 600 V �Qa � ° 1 4 a 2 5
Ezempiion for Reg.Maint,Elec�. ,� o � 4�(`)� •
SINGLE FAMIIY Temp.Power Pole 8 Appurtenances � � � �
HOME OWNER-BWLDER DECLARATION Sign wirh One Bronch Circvit �� � � 0 9.2 0-8 8 ,
I hnreby offirm thot I om?xempt(rom the Contractoi s Licens^ Addt�ionol Slgn Bronch Circui�s � -
law for the following reoson(Section 703I.5, 8usiness and - '
Professions Code):
❑ I,as owner oi the property,will do tha work and the M:sc.Conduifs 8 Cond�clors
struc�ure is not in�ended or offered foi sole(Sedion Other�See Complete Fee Sthedule�_ ,
7044,Business a�d Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is o construction lending agency!or �
the performance of the work for whith ihis permil is issued pERMIT FEE � (Sob-Total)
(Sec.3097,Civ.C.). �q0�„(,�`m�+��'��
PLAN CHECKING fEE � �
Lender's Name '
PERMIT ISSUING FEE �Q
tender's Address
I certiiy thot I have reod lhis application and stote iho�ihe TOTAL FEE .¢O�
above information is correcl.I agree lo comply with all County
oidinantes and 9ate laws regulating Electrical wi�ing,ond .
hereby outhorize represeniofives of this Counly to enler upon �
ihe obooe-r.ien�ioned properry for lnspecfon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture ef Permitiee Dote �
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