HomeMy WebLinkAbout0617A .WORKERS'COMPENSATIONDECLARATION 78A683 �o�e, qppLICATION FOR ELECTRICAL PERMIT �
I here6y affirm ihat I have a certilicate o1 consent to self insure, CE-Bo6G
or a certiticate of Nrorkers'Compensatbn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy there���Qe�a�3�I8�0�0.Lab.C.)
Policy NO.��Comva�y�NOvS�/!f�— FOR APPLICAN7 TO FlLL IN pD�RESS a y�a8'�.���,
❑ Certified copy is hereby turnished. . /N�• New Residential Bldgs&Poda1?7 EAC NO. FEE
�-�7, 1 8 2-Family,Sq.FC�,42L� S� — g LOCALITY� � �� � ,�
��yT Certifietl copy is fled with [he nty 6uildirg inspection _ �
'�'� ���y� MuNi-family Sq.Ft. NEnRES7
CROSS 5T.
.Date-f�APPiicant Residential Swimming Pools . O+�vNER OR p�
� . .. .� . flRM N4ME �/L.G��
� CERTIFlCATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light_Sw.— MA4 � /
- COMPENSATIONINSURANCE � nDDaESS �
(This section need not ba completed it the work involved by lhe First 20 CIT el.No.[� A,��
permit is Tor ate hundreA dollare(5100)or less.) � . Total No. Additionat P o����`/
PLAN CHECK •
I CBrtify�hat in the pEf(Olfn3nCB O(lhB wOAc}Of WhiCh thi3 pefmit ' ' APPLICANT
is issued,I sha�l not empby arry person in am/manner so as to
betome subject to the Wakers'Compensation Wws.,. . L'ghting Fixtures Frst 20 ADDRESS �
� � Totai No. Additional CITY , Tel.No.
Date MP��a�t - Fxed Appiiances Not Over 1 HP pERMIT /� //
�P'^ CE TO APPLICANT: If, after makin9�this Certificate of APp��qM T -t- ^ ��/
�• �ptbn,you should become suhject to the Nbrkers'Compensatbn Rarge_Heater_D.W.._ _
.pruvisions of the Labor Code,you must forthwith comply with wch Oven_Dryer_W.M._ AODRESS ���//�
provisions or ihis permit shall he deemed rewked. , ,., .Top���—fAU _W.H._ �� p/7� D� �jj �/
LICENSED CONTRAC70R5 DECLARATION Hood_Fan _Other_ CITY / a Tel.No. ���
J hereby affirm ihat I am licensed Under provison9 Of Chapter 9 Disp. _ Room Air Cond. — LICENSE OR � p- ���� �Q
�Commencing with S2CtiOr1 7000)Of DNiSi0f1 3 01 thB Bu5ine55 and REG.NUMBER d
Pr0(e551on5 COdO,efld Rry IiCBnSB IS ifl(u�l(0/CB a�d efleCt. OiSTRICi NO. PROCESSED OV
� Prnver Apparatus 8 Large Appliances � a
9�}/1 L}� C�O Size 8 Type HP,KW,KVA,or KVAR U ��-\d"1 O
L�ense Number /'�v b�7 L(c.Class � � Up to 1 Incl. � � FINAL V
��Z��� Date�CL� Over t to 10 Incl. DATE / . VALIDATON . . Q
Contractor_. �� ~
❑ Over 70 to 50 Incl. FlNAL C U
I am exempt under Sec. Over 50 to 700 Inc.. BY a
Over 100
B.&P.C.for this reason V7
� - Serviees,Swbd.,MCC 8 Panelboards � - - , `�� � � � �p 6 1,7 A ?
- -� Date: 0-200 Amp.Untler 600 V
Signature � � 207--1000 Amp.Under 600 V ' � � � - �• • • ° •2
❑ -� Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect. � • 1 0�8 6
�� � � �SINGLE FAMILY � � � Temp.Pd.ver Pole R Appurtenances . . • �;�J
HOME OWNER-BUILDER�ECLARATION Sign with One Branch Circuit � , O v� �
' �by affirm that I am exempt from the Confractor's License Law
�ie followirg reason(Section 703L5,Qusiness and Prc'assions �'dditional Sian&anch Circuils� Q A.�l�j—n r�
Code�:
❑ Misa Conduits&Conductors � - � �' �� �� - �
I,as owner of ihe pmperty,will do tha work and ihe s[ruCture Other(See Complete Fee SChedule)_
is not interxfea or offered for sale(Section 7044,Business �
and Professions Code1.
CANSTRUCTION LENDING AGENCY - � � -�
I hereby affirm that ihere is a construction lendirq agency lor the �
performance o1 the work(or which�his permit is issued(Sec.3097, PERMIT FEE (Sub•Total) �
Civ.Q).
PLAN CHECKING FEE� � � � - � �
Lender's Name '1 •
PERMIT ISSUING FEE � V �
Lender's Pddress
I certiy that 1 have read ihis appl'�cation and state that the a6ove TOTAL FEE . . ._ . _ . .. . . . . 0 .- . .
information is correct.1 agree to comply with all County ordinances .
and State laws regulating Electrical wiring,and hereby authorize .. . . . . .
reDresentatives of this Counry to enter upon the abo mentioned
�Orope for Inspectlon purposes. �SEE REVERSE FOR EXPLANATORY LANGUAGE�
�� �� �'
Si9naNre of Permrttee Date
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