HomeMy WebLinkAbout1470A WORKERS'COMPENSATtONDECLARATION � 76n663 �o,a, APPLICATION FOR ELECTRICAL PERMIT � � �
I hereby of(irm �hot I hove a certificole of consent to self � CE-Bo6G _
insure,or a cerJi'iicate of Workers'C pensation Insuran���ceyyy �QUNTY OF l05 ANGELES ' BUILDING AND SAFETY
,'( �a c�(�� �c'6pyprFye��/((Sec.3 0 '''JJJ c . .
w�aty J`d('�`�Company ��� �� fOR A►P/ICAM TO FILL IN JOB
Ceriified copy Is hereby furnished. New RasideNial Bldgs.8 Pools EACH n70. FEE ADORE55 ( �
� 1 8 2-Fdmil Ff. . . — E LOCALITY .
Cerrified copy is filed wiih the county building inspec- Y•59�
tion department. Multi-fomily$q.F�. — NEAREST
- . CROSS ST.
Da�e Applicanl Residenliol Swimming Pools F�iRM NAME �
� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlels•Rec_Liqht_$w._ �"w'��
�� -COMPENSATION INSURANCE - ' ADORE
Firsf 20
(Thts�t�cllen n��d not b�eompl�l�d Ii fhe work inrolwd by Totol No. Additionol CITY ( . Tel.No. , .
fhe permlf I�for ona hundrvd dollan(5100)or I�ss.) . .
PLA CHECK ' ,
I certi{y ihat in 1he performonce oi Ihe work for whlth�his APPLICANT -� �
permit is issued,I�shall nal employ any person in any monner -
so os�o become subject to ihe Workeri Compensation laws. lighting Fixtures First 40 ADDRES$ �
� � Tmol No. Addirionol qTY � Tel.No. .
Do1e Appliconr - Fixed Applionces No1 Over I HP PERnuT
NOTICE TO APPIICANT: If, afler moking this Certif7cote of APPLICANt �
Exemption, yau should become subjett to the Workeri Range_Heo�er_D.W._
Compensation provisions of the Lobor Code,you must forth• Oven _Dryer —W.M.— ADDRE55 � �
wilh comply wilh such provisions or Ihis permil sholl be 7op —FAU —W:H.— CITY p� /I
deemed revoked. - ' 6 -
. Hood _Fan _Other_
LICENSED CONTRACTORS DECIARATION IiCFNSE OR
I hereby affirm thot I om licensed under provisions of Chopier 9 Disp. _Room Air Cond. — REG.NUMBER Class.
�commencing wi�h Settion 7000)of Division 3 of the Business � DISTRICT NO. PROCESSED BY
Power Apparatus 8 Large Appliances >'
ond Professions CodG�and my license is in fuli force a eNed. - � - � � "� � - - 6.
� Size 8 Type HP,KW,INA,or KVAR� O V
license 6 Lit.Class � Up lo I Incl. FINAL -
DATE �c�/ � �
Over 1 to l0 incl. o���y yqLIDATIOH Q
Contra Dale Over 10 to 50 Incl. FINAL � V
❑ I am ezemp�under Sec. � Over 50�0 100 Int. 8Y C . . w
Over 100�-(��Q�/ �� (a���—.. �
8.8P.C.for this reason �' � / , Z
Services,Swbd.,MCC&Panelboords �„ - � -- � - -
Date: � .—0-Z00 Amp.Under 600 V �
� Signoture � ..401-1000 Amp.Under 600 V � . . .. .-- .
❑ . Ovar 1000 Amp.or Ovar 6pp V . .
E�emption for Reg.Main1.Eled.
SINGLE FAMILY � Temp.Power Pole&Appurtenances .
HOME OWNER-BUIIDER�ECLARATION Sign with One Bronch Circuit �
I hereby offirm that I am e�empt from the Contractoi s Litense p,�,����,,,,,,1$�gn R.�n�h Clrr��ita � � � - - . �
law for the rollowing reason j5ecnon 7031.5,business ond —
Professions Code): . .. � •�� (1 7.�A
❑ I,as owner of fhe praperfy,will do the work and the Miu.Conduifs 8 Conductors � � ,
shuc�ure is not imended or oHered for sale(Section O�her(See Complete Fee Schedule)— ► �• • • • •2
704A,Business and Prolesslons Code). . - '
I • •8550
CONSTRUCTION LENDING AGENCY - - �
�hereby af(irm that there is a mnsnuction lending agency for �.• • •$�5 Q� _
the performonce oi Ihe work for which Ihis permit is issued pERMIT FEE � (Sub-Totol) � � � - � -� - �
(sea 3ov�,e��.c.�. 0 2 1 0''8 4
� PLAN CHECKING FEE � - - �� � � �- � � - ----
lender's Nama .
PERMIT ISSUING FEE � 0 O .
lender's Address �
I ce ify ihat 1 hove reod this applica�ion and sto�e thot the - TOTAI FEE . . �ji� _ _. . _ ,
bo informotion is torrect.I agree 10 tomply wilh oll County .
or nonces end Stote lows re ting Electrical wiring,and �
reby au�hori representati s of this Cou ty to en�er up
\\ 'f• ione roper f r inspedi �urp� '
� � SEE REVERSE FOR EXPLANATORY LANGUAGE
�� ne of Permiuee � re � � � -
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