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HomeMy WebLinkAbout1059A ' WORKERS'COMPENSATIONDECLARATION ��`� �a�B1 APPLICATION FOR ELECTRICAL�PERMIT 1 � I hereby aifirm Ihat I have o certificate of consent io self . CE B06G � . , � insure,or a cer�ificate of Workers'Compensation Insurance, COUNTY OF LOS ANGEIES . BUILDING AND SAFETY . - or a certified copy,thereof(Sec.3800,Lab.C.)�� _ .. �� . � � � � . P❑ol�icy No��..��.. . .. Company- FOiI APPLIGNT(O flLl IN � JOB � . � F .. -. Cer�fied copy is hereby furnished. New Residential Bldgs.8 Pools �CH NO. FeE AODRESS, � �. Certified copy is tiled with the tounty building inspec- 1 8 2•Family,Sq.�Ft. �- s — E� � LOCALITY _ • . � tion deportment. , � Multi-family Sq.FI. — Ne.4RE5i .. ... , - � � � �— . Residential 5wimming Pools � CROSS St. � �Dafe � � Applimnt � . . . OWNEROR. � , � � � � . � FIRM NAME - � . '�'-�� . -CERTIFICATE OF EXEMPTION FROM WORKERS' y Outlets-Rec=Light_Sw._ � �'�'�"�� " COMPENSATION INSURANCE ' � ' � A�DRESS �+ � � F' � This saNbn a��d not ba com lalad if Iha work inrolvad b First 20 -''" �' . � � P � Totol No. Additional �' CITY ��� � - Tel No. � �� th�parmit i�for one hundrod dollon(SI00J or lass.) . � PL4N CHECK � � .. . I certify that in the performonce of the work for which tbis . . , � a i�qNt . . � � ' permit is issued,I sholl not employ ony person in ony monner � ' � .. . . - . .so as�o become subject to the Workers'Compensation Laws. lighting Fixtures Firs�20 � ADDRESS . � � � � - ' - - � Total No. �� Addirional � � � CITY � Tel.No. 'Da�e 4PPIimn� Fixed Appliances Nm Over 1 HP � PERM�T . . NOTICE TO APPLICANT: IF, after making this CeHificate of- � ' � Aav�i�e,NT�- � � � -� '� . � �.� �� Exemplion, you should 6ecome su6ject to-the Workers' Ranga_Heater_D.W._� � . Compensation provisians of Ihe Lobar Code,you musi forth• �Oren _Dryer _W.M.— AD�RESS � � . . � . . , . ,_ - wilh mmply with such provisions or this permit shall 6e Top� _FAU —W.H.— � � � deemed revoked. ' � Hood _Fan _Other_ � � CIN �,� � Tel.Na. ��� . � - IICENSED CONTRACTORS DECLARATION � � i����pg. � `• � I hereby offirm�thol I am licensed under proviaions of Chapier 9 Disp. _Room Air Cond. — REG.NUMBER � ' � Closs. , � (commencing with SeUion 7000)of Division 3 of the Business ' � DISTRICT NO. � - PROCESSED BY��`� � - } � -and Profeuions Code,and my license is in full force and effeU. Power Apparotus 8 Large Appliances � . a � $ize 8 Type HP,KW,KVA,or KVAR� /?��: -: � � License Number � Lic.Class - . . . w i . . Up to 1 Incl. FINAL . . . ' . . . - Over 1 to 101nc1. DATE / /� �i,h- � � � . LL j - �. Conuactor ' Date � . . �—I D�TjS VALIDATION .. ❑ . ..� �. Over 10 to 50 Ind. : � PINAL I am exempt under Sec Over 50 io 100 Inc. BY , � � ' 8.8P.C.for rh�s reoson � .O�er.100 �� h�n�� . � � . � � O � . � � � � � Services,$wbd.,MCC 8 Panelboards � � � � � � � � , : � � �ate:� . 0-Z00 Amp.Under 600 V . �,'`�`�� . � � . . � � . . Signarure � .. � .. �201-1000 Amp.Under 600 V � � � � � ._-: r � �� . .. Over 1000 Amp.or Over 600 V � . � . ' - - � � Exemption for Reg.Maint.Elect. � -� � �SINGLE FAMILY � Temp.Power Pole&Appurtendnces � " . - . � � ' ' �,HOME OWNER•BUILDER DECLARATION - Sign with One Bmnch Circuit � • �: I tKreby nffirm thot I om exempt from the CoNractor's license � qddiiional Sign Branch Circuits � � � � � . � �. � +'�j1�++s 4 t� �- � ' law for�he iollowing reason(Section 7031.5,B�siness and < . . � � . �I , � ���Professions Code): - � . . - �� �"'� � - � - , . �. � 4 �:� i .: t� G� � � . � � � ' . Misc..Conduits&Conducfors � . � ' . ,�, � �I,os owner of the property,will do the work and Ihe ! ��i� ���� � structure is not in�ended or offered for sale (Sedion ��her(See Completa Fee Sched�le�_ , �� - __ � 7044,Business and ProFessions CodeJ. � � � , . ���r-����M�r. � �� � �� CONSTRUCTION 1EN01NG AGENCY� �� � � � �� f-hereby affirm that there is a construcrion lending agency for . . . � � �' � (q;j�,�J�. ��a �. ��� .<'the�performonce af the work far which�his permit.is issued PERMIT FEE � . � (Sub-Total) � � . � � � � � - . ' � .. (Sec:3097,Civ.C.J. � . . . . -. - . � . . � . . . . . , . . I�.. . . � � � PLAN CHECKING FEE � �� � � . �� , � - ( . . Lender's Name . . . . � . . . . ' � � - . � . � � PERMIT ISSUING FEE - � - � . ' � Lender's Address � � - � �� . . ' - . ' � � � � - � � . I certify thot I have reod this opplicotion and siate that the TOTAL FEE � � „r^',',�.� " � � . , . .. � �obove iniormalion is wrrect.I agree lo camply with oll County . _. � � � . ordinances and State laws regulating Electriml wiring,and � � _ � � . . � �� �,.yL � . � . � .� � . � . hereby aulhorize represenlalives of this County to enter upon � . � � � � . } :r.y � - � . . . , . � the ahove-mentioned properry for inspedion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i � ...�-. .'.. ' . . . . ... . , '1ti . � . . . ..� . . . .. . . , . �� . � - .. . JignoWre of Permiuee � - �ate . . � - . . ' � . . . . . . _ . . � . � ... .- � . .. . � . � .. - . : . . , . .. . .� . .. ..,. . - . . .. . .. '.:,� . . � . _ � -- , j— r—� , _ . - : _ ^i(� 1--� (--� - C ; . �:• � F c - C �-- � . :'i__.: .. ' "r c i .. �!': . ' .� � V C �� �, I - . ` �r — ✓ , ��, c . . � I �i - ' i. � �: I - _ ' � � , � -, c - -f � � ��� � ! � - - c: � i. I - � I , j � _(1 . - - .. If. c - . 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