HomeMy WebLinkAbout0616A - ,WORKERS'COMPENSATIONDECLARATION 76A663 �a�e� qppLICATION FOR ELECTRICAL PERMIT {�
I here6y affiim that I have a certilicale o1 consent to self insure, CE-8o6G
or a certiticate of Workers'Compensation Inwrance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY LJ
copy the2o�F(Se�c}.�3��8p0)0�.L�a6.C.) /
PoIiCy NO.��"'!S!J_l27COmpefly��DUS7I��� i0R APPLICANT TO FlLL IN ,qppqESS re i(,
❑ Certified copy is here6y fumished. f�� New Residential Bldgs.8 Pool EACH NO. FEE '
I[7� 1&2-Famil �j� 5 — S LOCALITY ��^�7� r
LS� �r'fied copy is liled with the county building inspection y���F�� _
NEAf7EST
arime t��..py/� Multi-family Sq.Ft. Ca05S 5T.
Date� o V AppliCant C Residentiat Swimming Pools OwNER Oa n- p�•
FIRM NAME lT l.4
CERTIFICATE OF EXEMPTION FROM WORKERS'. putlets Rec—Light_Sw.— �^A��� 3�S—� �� ��
-� - COMPENSATIONINSURANCE � � a�DRESS
(This section need not be compteted it the work involved by the Fiist 20
permit is for one hundred dollars($100)or less.) . Total No. Atltlitional CIT el.No. �
�I certify ihat in ihe performance of iha wo�k for vfiich this permit aPi'L�cnnrr K
IS i55Ued,I Shall not employ arry per50n in any manner 5o as to
�become subiect to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
- � � � Total No. � Additional GTY Tel.No.
Date �Applicant - Rxed Appliances Not Over 1 HP
N�1pCE TO APPLICANT: If, aker making this Certificate of PER�niT �j �� �, r
Ran e_Heater_ DW. _ AP��'M
, ptan,you should become subjed b lhe Workers'Compensation 9
{,�,..sions of the La6or Code,you must forthwith comply with such Oven—�ryer_ W.M._ A�DRESS � �
provisions or this permi�shall be deemetl revoke0. Top _FAU _ W.H._ . - � CITY�� • �7O Tel.No.
LICENSED CONTRACTORS DECLARATION Hood—Fan _ Olher_
I hereby alfirm thzt I am licensed under provisions ot Chapter 9 UCENSE OR Q�� �
(commencing with Section 700D)01 Division 3 of the Business and � �Disp. —Room Air Cord. _ FtEG.NUMaEa <}�.:.7 ��'s�:f b
Rofessions Code,aM my license is in full force and effect. oismici No. PaOCe55e�9v �
Povrer Apparatus 8 Large Applianees y�,
�n�O l C„� Size S Type HP,KW,KVA,or K4AR � D 1'\p�0 1 G U
License Number �T���� Lia Class' ` Up to 1 Incl. FlNAL
Contractor�L-Z��� �Date ' / A Over 1 to t0lncl. �A� �� ��`"� VALIDA710N �
Over 10 to 50 Incl. U
❑ I am ezempt under Sec. Over 50 to 100 Inc. F�AL /
8.8P.C.for ihis reason Over 100 '�'�""'� ����,6/� �'
N
Services,Swbd.,MCC&Panelboards - � � �� � o e �2 Z
�Date: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V I • 1 0 a 8 6
❑ - Over 7000 Amp.or Ovei 600 V
Ezemption Por Reg.MaiM.Elect. � __
• e � OJ,':h�
�� � � �5!NGLE FA6"!LY Temp.Pow=r Po!e 8 ACP��ten2nces
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o�0 5—F�3
by affirm that I am exempt from the Contractor's License Law pdditional Sign Branch Circuits
e foltowing reason(Section 7031.5.Business and Professions �
Co el:
❑ I,as owner of ihe ro rt will do the work and the structure Misa CaMuits&Conductors .
p � Y' O[her See Complete Fee Schedule)_
is not interxled or olfered for sale(Section 7044,Business � .
and Professions Code). � - � - � �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construcYbn IeMirg agency for the
performance ot the work for whlch ihis permit is issued(Sec.3097,. pERM(T FEE- - �� - � � (Sub-Totall � .
CN.C.). '
PLAN CHECKING FEE . . .
Lender's Name
PERMR ISSl11NG FEE , . �D� .
,Lender's Address /�
I certify that I have read thls applicatbn aM state that tha above TOTAL FEE '
information is correct.I agree to comply with all CouMy ordinar�ces
and State laws regulating EIeCt�Ical wiring,and hereby authodze
repres tatives of this County to enter upon the aho -mentioned �� � �
pro for Inspectlon purposes. �
��� . _. SEE REVERSE FOR EXPLANATORY LANGUAGE .
�
Signature ot Permittee Date
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