HomeMy WebLinkAbout0586A WORKERS'COMPENSATIONDECLARATION 76A663 10/et APpLICATION FOR ELECTRICAL-PERMIT
� 1 hereby affirm that I have a certificate of consent to self insure, CE-806G �
or a certificate of Workers'CompensaGon Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy there�o.rf-(Sye�c�.3800,Lab.C.) � � j��.
Policy No._�✓�✓��c3G 3�mp3�f/1/'�(/�7L/� FOR AAPLICANT TO FllL IN JOB '1 ��/� L
❑ Certified copy is hereb Turnished. �~�, EACH NO. FEE AODRESS�'�.SrU / N
Y New Residential Bldgs.8 Pools
� Certified copy is filed with the county building inspection 1 8 2-Family,Sq.FL `� — 5 LOCALRY ���� � S r�
llma L �f Mulli-iamily Sq.FS. NEAREST D
�/n� CPOSS ST.
�ate '� Applicant ✓�.lJ�i Residential Swimming Pools OWNER oR !.
FIRM N0.ME��L� ,Z
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—L'ght_Sw.— R�^��
COMPENSATION INSURANCE aooness�D/ C�L-� ` Z/f�.
(7his sectbn need not be compleletl N the work Involved by the First 20 �
permit ia for one hundred dollars($100)or lees.) Tolai No. Atltli[ional CIT���y��v � ��s Tel.N.�j� ,s�fl
� I certify that in the performance of the vrork lor which this permit - Pv�Ct+eCK . i�
is issuetl,I shall not employ arry person in any manner so as to - ' APPLICANT
become subject[o the Workers'Compensation Laws. � Lighling Fixtures First 20 ADORESS �
Total Na. 'Addilional
Dat Applicant CITY Tel.No.
�, Fixetl ApplianCes Not Over 1 HP
1� E TO APPLICANT: If, aftcr making lhis Certiticate of PE�Mir u�� p�"��
� ption,you sFwuld become subject to(he Workers'Compensalion Range_Heater_ D.W. _ APPLICANi (,.��� ��'/L
1 ions or ths pebmit shae be deemedorel�ieh�comply with such Oven_Dryer_ W.M._ ADDRESS ,D, �J��
� ToP — FAU _ W.H._ . CITY���� . g�,o8 Tel.No�f��p y�/
LICENSED CONTRACTORS DECLARATION Hood—Fan _ Other_
� I herety aflirm that I um licensetl under provisions oF Chapter 9 Disp. _ Room Air Cond. _ uCENSE oR (�'A��f� ^
(commencing with Section 7000)oi DNlsion 3 Of IhC BUSinC55�ntl REG.NU1.7BER j�L/C.�) C�`'` ��
PfofC55i0n5 CAdO,e0d fny IiCense iS In tull�OrC2 2nd B11eCt OtSTRICT NO. PROCESSE v a
Powcr Apparatus&Largo Appliances ,
/�� p7 Size&Type HP,KW,KVA,or KUAR �� �O � al.`(L d
License Number. 7 7�UOJ Lk.Class C�0 Up to 1 Incl. DATE / (�v �
�jC�?fC-� 4f/'L Date �� � Ovcr 1 ta fOlncl. -/L- d VALIDATION _ �
CoNractor Over 70 to 50 1ncl. �...
❑ . . FINA . , V
I am exempt under Sec. Over 50 to 100 Inc. gy
B.&P.C.For this reason Over 700 N
. Services,Swbd.,MCC 8 Panelboards , � Z
Date: - 0-200 Amp.Under 600 V
SiBnature 201-1000 Amp.Under 600 V ' � �
❑ Over 1000 Amp.or Over 600 V �
Exemption for Reg.MainL Elect ��J�8.��
SINGLE FAMI�V Temp.Power Pale d Appur�enanCes {�o
HOME OWNER-BUILDER DECLARATION Sign with Ono Branch Circuit ; • • e o
I hereby attirm that I am exempt Irom ihe Contractor's License Law
�at�the following reason(Section 7031.5,Business and Prvfessions Adtlitional Sign Branch Circuits � .
.e):
Misa Conduits 8 Conductors � ' � • '3 Q,7 5
. � I,as owner of thc pmperty,will do the work and lhe siructure
. is not in[ended or olfered for sale ISection 7044,8usiness Other[See Complete Fee ScheCule)_ '
and Professions Code). � �
CONSTRUCTION LENDING AGENCY 5� l� � .� • • •3 0,7 5�
I hereby alfirm ihat there Is a conslruction lendinp agency for ihe �
� performance of Ihe vrork For which this permit is issued(Sea 3097, pERM1T FEE (Suh-Total) � � �&'Q 5-8$
Civ.C.�. '.
� PLAN CHECKING FEE �
Lender's Name '�
PERM�T ISSUING FEE V � .
Lender's Address '�
I certify that I have read ihis application and stale that the abwe TOTAL FEE � '� ,
information is cormct.I agree to comply with sll County ordinances
and State laws regulating Eledrical wiring, and hereby authorize �
representatives of this County to enter upon�he above-mentioned ��
proyq�y for inSpECliOn pufpose5. �
� / � _ _�e � SEE REVERSE FOR EXPLANATORY LANGUAGE ��
�II e. ri- �v r
CL�Z-/ ✓�1
SignaNre of Permittee Date ��
. _ , . ,
___ __ ._.. ... _ _ _
....__ . . . .._
. � , ' APPAOvaLS � DATE ���GrEiq7ur�E � - - � - � ' � . OWNER-BUILDHR DECLARATION ;
� • � �TEMP.POWEq POLE . _ � � � I�hercby affirm tha[I am ezempt from the Gontractor's License
. � . . �. _ . lav+for ihe tollowirtt7 reason(Sectim 7031.5,Bus��ss arM
� UNDERSLAB WORK _ . � Prolesslons Code):Any cify a county which reqmms a pemrit
ROUGH CON�UIT . � � . � � �N corrsGvci,alter,Mprove,demolish,or ropair any struc4.m,pria
� �- !o!ts issuance,also�roquires fhe a,�pfirartt ler such permit to lile
� . � . WIRING � � . . a sifiod siatement Nuf he is frcensed pursuanl to the provisons
• - � - � FlXTURES �- � . . o!Me Con,racror's License Lsw(Chapter 9(eommcvicing with
� Secfion 7000J o!Division 3 of tho 8usiriess and Professtms
� � �� � " ,- PO'NER�AUTHORIZED � � � Code) or Ihat he 7s exempt thcrclrwrt and the basrs for fhe
�- -- -�-� � - UTILITV CO.NOTIFIED �'r( � , alleged exemption Any vidation cl Section 7031.5 hy any
. applicarrt tw p permit subjects tAe epplicant fo a ciWl penatty
� �� � FlNAL �L'11CCY Of1 FY0J1L � - ol rrot molc lhan fivc hundred do1Lv5(5500Jr
' � NO7ES � � - " _ ❑I,os owner of�he property will do Ihe viork,and the
��- -� � � . structure is not intended or offered for sale. -
. . _ � � � � fSea 7044,Business and Pro!essions Code: The Con^�r's
, . . . , Ucense Law does irot apply to a�amer ol prc�perfy whi .�„
� . . _ � � � . � - w Improves lhcreon,end who daes siich wak himsell F 'eF�
, . that Such Improvemen:s am not infendM or olfcred!w� ...Ss-�
-�- � � � � -� � - � �� � - - � however,the buildng w improvrment rs sokl within one ye��o!
_ _ , _ _ canpletion,(he avner•bui'der wiU hsm the burdcn ot proving 1ha1
� "� � " �' - . -� � � � � he tlitl not bu�ld or lmp�ove fa 1he purposc ol salc.J
� � � , I am exempt under Sec. ,
. . - 6&P.C.tor this reason �
Date
Owner
. � ,