HomeMy WebLinkAbout1694A (17) I �,�-'f?� LlC�-I'T/NG �`
WORKERS'COMPENSATIONDECLARATION 76A663 ,o,B, .qppLICATION FOR ELECTRICAL PERMIT �� \
I hereby alfirm that I have a certificate oi consent to self insure,, ce-eoec
or a certificate of Workers Compensation Insurance,or a certitied COUNTY OF LOS ANGELES � Z B ILDING AND SAFETY
copy thereof(Sea 3800.Lab.C.) � i
PoIiCy ND. ' Camp�ny FOR APPLICANT TO FlLL IN � JOB
❑ Certified co is hereh furnished � EACH NO. FEE � �DaEs ) /'
. PY Y New Residential Bldgs.8 Pools .
-� Certified�copy is filed with the counry building inspection�� 1 8 2•Family,Sq.Ft. 5 — 5 , j LOCALITY �
I NEAREST i
departmeM. - ' ' Multi-family Sq.Ft. caoss St yf l/ •
Date � Applicant Residential Swimming Pools � a,rNER oq �
►-� t ' FIRM NAME L� rs
CERTIFICATE OF EXEMPTION FROM WORKERS' p�tlets:Rec�L'ght f'L Sw.— � MAiL 1'A /
COMPENSATION INSURANCE + � � � MDRES � UE� �/ D
(Thie aeelion need not be completed VI the work Invotved by the i' Frst 20
permil is lor one hundred dollars($100)or less.) Total No.� Additional f CITY � ����
I certify that in the performance of the work tor which this permit - [�'� PL-hN CHEG /i
is issued,I shall rrot empioy arry person in airy manner so as to " � '���M `����
become subject to lhe Workers'Compensation Laws. _ L'ghtirg Fixtu�� Flrst 20 � / � � � ADDRESS Q�(/J � G!
Additional �7 / � 4(�s�LC,(J�4i • �� -�
� Total No. i qTY
Date Applicant � Fxed Appliances Not Over 1 HP �S U
NOTICE TO APPLICANT: If, after makirg this Certificate of PERMii .
Eaemption,you should become su6ject to lhe Workers'Compensation Range_Heater_D.W. _ �� AP%JCANT
provisions of the Labor Code,you must forthwith compiy with such Oven_Dryei_ W.M._ i ADORESS
provisions or this permit shall be deemed revoked. , - Top —FAU _ W,H.-_ � qTV Tel.No.
- � LICENSE�CANTRACTOFS DECLAF7ATION Hood—Fan _ Other_ j
1 hereby affirm that I am licensed untler provisions of Chapter 9- Disp. _ Room Alr Cond. _ ���'tN����� Class. � �
(commencing with Section 7000)ol Division 3 of tha Business and � REG.NunneER
Professions Code,and my license is in full lorce and effect. p�,yer Apparztus 8 Large Appliances - i OISTF71�7 NO. PROLES�B��
Size&Type HP,KW.KUA,or KVAR I� p
License Number Lic.Class Up l0 1 IncL � FINAL V
. Over 1 t0 701nG1. �A� VALI�ATION �
Contractor Date Over 10 to 50 Incl. �
FINAL
❑ I am exempt under Sec. � " Over 50 ta 100 Inc. gY � � �� � �� � W
B.SP.C.for this reason Over 100 � n-
Services,Swbd.,MCC 8 Parielhoards �� �� 6 9,4 h z
- Date: 0-200 Amp.Under 600 V '� 2 � � �
Signa[ure 201-1000 Amp.llnder 600 V � �' �• • • • � 9
� Over 1000 Amp.or Over 600 V �
ExempFron for Reg.Maint.Elect. � • � C N'�5
SINGLE FAMILY Temp.Power Pole&AppuAenances , r x
HOME OWNER-BU40ER DECLARATION • • � O 5�7 J c�
I here6y af(irm ihat I am exempt from the Contractor's License Law Sign with One Branch Circuit � •L2�
".ddi:io^�!c:;^o.a.rh Csc.:i!s / _n n n_o 0
ior tne foliowing reason jSection 7031.5,6usiness and Rofessions � �,2 v v� �
Code):
❑ 1,as owner of the property,will do lhe work and the slructure Mise.Conduits&Conductors �
is not inlended or olfered For sale(Section 7044,Business . Other(See Complete Fee Schedute)_ , �
and RnFessions Code).
CONSTRUCTION LEN�ING AGENCY � �
I he2by aflirm tha[there i3 a ConstfuCtion lendirg agenCy for the r�
performance of the vrork for which this pe�mit is issued(Sec.3097, ' pERM1T FEE - (Sub-Totaq " ,�Q�5�J
�
��.�.,. 3'0%�rrt����"a.� i 03,�5 M1�,��
PLAN CHECKING FEE r �
Lender's Name
� PERMIT ISSUING FEE � � �
Lender's Address ^
I certify that I have read this application antl state that the above TOTAL FEE 1��1
informafron is correct I a9ree to comply with all County ortlinances
and State laws regulating Electrical wiring,and here6y authorize �
representatives of this County to enter upon the above-mentioned ,
properfy for inspection purposes. �
� � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ot Permittee �ale �
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