HomeMy WebLinkAbout1265A (11)W'ORKERS'CO-N+PENSATION DECLARATION CE -86(2.80) .APPLICATION FOR ELECTRICAL PERMIT .
1 hereby affirm that 1 have a certificate of consent to self - COUNTY OF LOS ANGELES - . . BUILDING AND SAFETY
insure, or a certificate of Workers' Compensation Insurance, or
— — - -
-
a certified copy thereof (Sec. 3800 ab. CJ
FOR APPLICANT TO FILL IN
Tel No.
Policy No. Company
New Residential Bldgs. & Pools - EACH IND.
FEI
_Certified copy is hereby furnished.
1 & 2-Family,Sq. Ft. $ —
$
J.--
Certified copy is filed wco
ith the c unty buil 'rg in on
❑
Multi-family Sq. Ft.
department.
Residential Swimming Pools
CITY
Tel No.
DateL� Applicant
Outlets: Rec.—Light— Sw._
LLI
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS'
Total No. Additional
COMPENSATION INSURANCE
-
�j r,� TO No.
(This section need not be completed if the work involved
Lighting Fixtures first 20
JIGCIass
by the permit is for one hundred dollars ($100) or less.)
Additional
-
Total No.
O
1 certify that in the performance of the work for which this
Fixed Appliances Not Over 1 HP
permit is issued, i shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Range_ Heater_ D.W. _
-
Oven -_ Dryer _ W.M.
- Date Applicant
Top- _ FAU _ W.H.
Hood _ Fan —Other—
Other—
NOTICE TO APPLICANT: If, after making this Certificate of
NOTICE
Disp. _Room Air Cond.—
Exemption. you shnuld become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
Power Apparatus & Large Appliances
with comply with such provisions or this permit shall be
Size &Type HP, KW, KVA, or KVAR -
deemed revoked.
Up to 1 Incl.
Over 1 to 10 Incl.
LICENSED CONTRACTORS DECLARATION
Over 10 to 50 Incl.
Ihereby affirm that I am licensed under provisions of Chapter
Over 50 to 100 Inc.
9 (commencing with Section.7000) of Division 3 of the Busi-
Over 100
ness and Professions. Code, and my license is in full force and
effect.
Services
0.200 Amp. Under 600 V
License Number Lie. Class
201.1000 Amp. Under 600 V
ContractorH I01 tf k Date
Over 1000 Amp, or Over 600 V
HOME OWNER -BUILDER DECLARATION
Temp. Power Pole & Appurtenances
I hereby affirm that I am exempt from the Contractor's
Sign with One Branch Circuit
License Law for the following reason (Section '70 31.5, Rusi.
Additional Sign Branch Circuits
ness and Professions Code):
F1 1, owner of the do the work and the
Mise. Conduits &Conductors
as property, will
structure is not intended or offered for sale (Section
Other (See Complete Fee Schedule)—
7044, Business and Professions Code). -
. CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency
-
for the performance of the work for which this permit is
PERMIT FEE (Sub -Total)
issued (Sec. 3097, Civ. C.).
Lender's Name
PLAN CHECKING FEE (One -Fourth Permit Fee)
Lender's Address
PERMIT ISSUING FEE -
1 certify that I have read this application and state that the
TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and -
hereby auth ize represents[' sof tris County to enter upon
t a ov
- n 'oned oper y r i p cticn purposes.
SEEREVERSE FOR EXPLANATORY LANGUAGE
Signature
of Permittee Date
JOB
ADDRESS
LOCALITY
ill
MAIL - - -
— — - -
-
AODRESS
CITY
Tel No.
}
PLAN CHECK
a
APPLICANT
Ov
ADDRESS
CITY
Tel No.
0
PERMIT
LLI
APPLICANT
d
ADDRESS 17
Z
CITY -�'
�j r,� TO No.
LICENSE OR9t
REO. NUMBER ZSi
JIGCIass
DISTRICT NO.
PROCESSED BY
O
FINAL
DATE 5
VALIDATION
21265A
#.....2
1••2050
•••2050
0'1.13=82
a�
`n•
.
-^
.' G^ f-
O
c v' �: ' �, .fig, ory� c
Oi'nvQ� oCr � cC'•�_ �: �
SCG.
co
1
_
e
4Z
`J