HomeMy WebLinkAbout0902A WORKERS'COMPENSATION OKLARATION 76n663 ,o,B�� APPLICATION FOR ELECTRICAL PERMIT �
I hereby�6fiirm ihat I hove a cer��fimte of consent�o self CE-B06G .
�nswe,or a cerr�fitote of Workers'Compenwtion Insurance, COUNTY F LOS ANGELES BUILDING AND$AFETY
orp certiii�cg�y the�eof($ec.3 Lob.C.) � -
(171J10 c� � FOR APPLICAM TO flll IN 10B
0❑oliZy�7�. v �ompany ADDRE � �
Certified copy is hereby furnished. . New Residentiol Bldgs..�f�Is/� EACH NO. FEE�
1&2-Fomil Ft.,�SL s — s LOCALIN
�Certified copy is filed wi�h the county building insper Y•�1• . , _
ti n de imenl. - �Multi•family Sq.Ft. NEAREST
CROSS ST.
�� Dote Applicon��Q�4� Residential Swimming Pools pRM N.�E � �
� CERTIFICATE OF EXEMPTION FROM WORKERS' � Outlets:Rac�L_Lighr�5w.� Ni41L �
COMPENSATION INSURANCE ADDRE55
�/� First 40
1�Thi:aMion n�ad not bs eomplafed if fhs work invoiv�d by Total No.L�l_ Additional � �I Tel.N . �
�v p�rm�f ia for one hu�nd dollors(SI00)or las.) �
iertify fhot in the performance of ihe work for which this , �/+N CHKK
APPLI�'.4M .
--- mit is issued,I shall not employ any person in ony monnar '._
s to become subject to the Woikers'Compensotion Laws. Lighting Fiatures - First 20 � DDRESS �
- - � Total No.� Additianal CIN Tal.No. I
' Applimnl " Fixad Applionces No1 Over 1 HP PERMiT �
{hu ICE TO APPLICANT: If, of�er making �his Certifimte o{ - APPLICANT
f EKemption, you sho�ld become subject to the Workers' Range_Heater_D.W.— i
Ccmpensaficn provisions of ihe lo6or Code,yov must iorth- Oven _�ryer _W.M.— � ADDRE55`7
wi�h comply with such provisions or �his permit shall be Top _FAU_ —W.H.— CIT Tel.No �
deemed revoked. � Hood _Fon _Other_ �
IICENSED CONTRACTORS DECLARATION � uCENSE OR !
I hereby offirm Ihot l am licensed vndar provisions of Chapter 9 -Disp. _Room Air Cond.�— REG.NUMBER � � ���Ou'C ;
(commencing wiih Section 7000)oi Division 9 oi the Bosiness DISTRICT NO. PROCESSED BY } I
ond Professions Code,ond my license is in full force and effecl. Power Apporotus&Lorge Appliantes �� . �Q O h O
Q�� Size 8 Type HP,KW,KVA,or KVAR�
license Number 41�'�*� Lic.Class '� '�-- Up to 1 Ind. � FINAI ' V �,
�ATE O
�Q' .l r� Over�1 to 10 Incl. �/�� VALIDATION r '
Contrador �-+���� Date I�TL Over 10 to 50 Ind. FINAL ^ ,� W .i
❑ I am exempt under Sec. ' � Over 50 to 100 Inc. gY / Y L� . . y I
Ovar 100 �' �
. 8.8P.C.for Ihis reosan . � Z '
�Dofe: Sarvites,Swbd.,MCC 8 Panelboards �
0-200 Amp.Under 600 V
Signature � � 201-1000 Amp.Under 600 V - . . .. I
OOver 1000 Amp.or Over 600 V � ;
Exemption for Reg.Mvint Elect. � �
_ � SINGLE FAMILY . %O 9 Q Z A '
. Temp.Power Pole 8 Appurfenonces ��
� HOME OWNER-BUILDER DECLARATION Sign wi�h One Bronch Circuit
f� I hereby affi�m iha�I am eaempt from the Contractor's Litense _ L'a • • • i 2 .
Law for the fo�lowing�eoson(Sedion 7031.5,Business and ^��'''cncl Siyn°rcn:h Ci:;vi!: '
Proiessions Code): I •2 9 3 8 5
❑ I,os owner of ihe properly,will da the work and the Misc.Conduits 8 Condudors � � � � �
strvdure is na�intended or offered Tor sale(SeUion _ Other_(See Complete Fee Schedule�_ ► . b a�9 a 6 5 c=>
7044,Business ond Professions Code). ��,�O_8 7
CONSTRUCTION LENDING AGENCY . . � ��- - �-
I hereby affirm that there is a conslroction lending agency for �
fhe periormance of the work for which Ihis permit is issued PERMIT FEE � � - � (Sub-Totol) � � �� ��-� � �-�� � - �
(Sec.3097.Civ.C.). � . .
PIAN CHECKING FEE - - -- '
lender's Nome � �
PERMIT ISSUING FEE . . . '�
Lender's Address -
I certiiy thol I hava read this application ond sta�e tha�.lhe TOTAL FEE �
obove information is correct.I agree�o tompiy with all County . . _
ordinances ond S�ate lows regulating Electrital w�ring,and _ _ . . -
hereFyr outhorize represen�atives of Ihis County to enter upon .. �
the obove•men�ioned property(or inspeclion p�rposes SEE REVERSE FOR EXPLANATORY LANGUAGE _
c0.;,r, o.r.c,no "1'a'd,� �-'
Signalore of Perminee Date . � _ . - /�
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