HomeMy WebLinkAbout1369AWORKERS' COMPENSATION DECLARATION 76A663 10/61 APPLICATION FOR ELECTRICAL PERMIT
Gnereby at that I have a certificate 01 consent to self insure, CE -806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (Sec. 3800.Leb. C.)
Policy Ncx - Company -
❑ Certified copy is hereby furnished.
-❑ -Certified copy is filed with the county building inspection
department. .
Date Applicant -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the work Involved by the
permit Is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this permit
is issued, I Shall not employ any person In any manner so as to
become subject
Date��Mttococ??the Workers' C�Workes'Cfmipen'seafion
1i11— ApplicantNOTICE TO APPLICANT:, If,afteofExemption, you should become subjecon _
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 _
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, andUmy license is in full force and effect.
License Number ` O' 9 Lia. Class
Contraclto�r{ -} 5 ^L Date
❑ I `rte 3,1p'ltnder M_Z C , Cp
BAP.C. for this reason
Data.
Signature
❑ Exemption for Reg. Maint. Elect. ..
- - SINGLE FAMILY - -
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law
fnr the followingn u -___(Sscfinn 7031 F, Bus...__., a^d Profo..,,.,,ns
Code):
❑ I, as owner of the property, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097,
Civ. C.).
Lender's Name
Lenders Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all County ordinances
FOR APPLICANT TO FILL IN - -
JOB
New Residential Bldgs. 8 Pools
EACH NO.
FEE ADDRESS
1 & 2 -Family, Sq. Ft.
S — S
LOCALITY
Multi -family Sq. Ft.
NEARE6T
Residential. Swimming Pools
CROSS O -
OWNER OR
Jq
Pee
_
FIRM NAME j
MAIL
Outlets: Light 11 Sw.r�
J
ADDRESS
M First 20
CITY
Total No. Additional
vL
PLAN C E
r
. APPLICANT
Lighting Fixtures First 20
J
ADDRESS
al
Additional
_
Total No.
CITY - -
Fixed Appliances No Over 1 HP
PERMIT
Range— Heater DW. —
APPLICANT e
Oven — Dryer — WM. -_
- -
ADDRESS
Top — FAU — W.H.
,
.. —
Hood — Fan — -Other—
4444
CITY V
Disp..— Room Air Cond.
UCENSEOH
—
REG. NUMBER
Power Apparatus & Large AppliancesDISTRICT
NO.
.___..
f v
Size & Type HP, KW, KVA, or KVAR
-'Up to 1 Incl.- - -
FINAL -
Over 1 to 10 ?net.
DATE
U
Over 10 to SO Incl.
. Over 50 to 100 Inc.
FINAL / �
Over 100
Services, Swbd„ MCC & Panelboards
0 - 200 Amp. Under 600 V f
201'- 1000 Amp. Under 600 V-
-- - -
-- -- '
Over 1000 Amp. or r 600 V
Temp. Power Pole /& Appu enances
Sign with One Branch Circuit
- - -- - -
Additional Sign Branch Circuits
Misc. Conduits & Conductors -
- -
Other (See Complete Fee Schedule)
7—
Z
PERMIT FEE - -
(Sub -Total)
Tel. No.
Tel. No.
t
Te
Cl
PROCESSED BY
VALIDATION
13C19A
#•4••.2
1.47275
•.•7275Q'
09.06-88
PLAN CHECKING FEE....-.
_
PERMIT ISSUING FEE
TOTAL FEE
and State laws regulating Electrical wiring, and hereby authorize
representatives of ns County to enter upon the above-mentioned - -
party for I pec In As,
SEE REVERSE FOR EXPLANATORY LANGUAGE
.y ature of Permits V
Date
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