HomeMy WebLinkAbout0903A _ �
WORKERS'COMPENSATIONDECLARATION �6.� �o,e, APPLICATION FOR ELECTRICAL PERMIT - �
I hereby oyirm thot I hove o certifim�e of consenf fo self GE-806('
�nsure,or o certificare of Workers'Compensation Insu�ance, COU TY OF LOS ANGELES BUILDING AND SAFETY
or 6�f$��ti(i��ereof(Sec.3 Lab,C.)_ � .
a[y I�o` Compan��G FOR APPLICANT TO Flll IN �Ob � - _
Certified copy if hereby iurnished. New Residentivl Bldgs.� EACH � NO. FEE ADDRE
1 8 2-Famil Ft. f — S LOCALITY
�'Certified copy is filad with ihe co�nty building inspea Y.S9� _ �
lion department. � �Multi-family Sq.Ft.'� NfAREST . . .
0/� Residential Swimming Vools OwraER T
Date�—Appliwnt t y1-�4� � , . _
r1 r�, FIRM NAME'
CERTIFICATE OF EXEMPTION FROM WORKERS' OWletd:Rec��n Light,�._Sw� � '�4P'�� -
� COMVENSATION INSURANCE - - � � ADDRE55 �
This�scfion nNd not b�wm INed lf ths�work involvad b y, ' Firsf 20
� P � Total No.L� Addiiional - � CIT .. iel.N .
th�permll ff lor on�hundrod dollars(SI00)or I�fi.)
I cerlif �hot in ihe erformonte oi the work for whith this . PL4N CMECK
Y P APPLICANT
permit is issued,I sholl not employ any person in any manner � -- -
so as fo become sobject to the Worke�i Compensofion Lawz. LigMing Piaturos� �Firsf 1b ADDRESS � - �
—� � � � Additionol
Totol No. CITY Tel.No.�
� 4pplicant Fixed Appliances Not Over 1 HP PERMR
,�hoflCE TO APPUCANT: If, ofter makinq this Cartificate-of � APPtICANT
Exemprion, you should become subject to Ihe Wwkers' Range_Heoier_D.W.—
Compensotion provisians of the Labor Code,you must for�h• Oven _Dryer _W.M.— . ADORESS �
iih comply w'�b such provisions or rhis permit shall be Top _FAU _W.H.— �
deemed revoked. � - � - Haod �Fan _Other_ �� iel.N -
LICENSED CONTRACTORS DECLARATION � LKENSE Ok �
�herc6y affi�m thol I am litensed ander provisions of Chapter 9 Disp.-_Room Air Cond. — RFG.NUMBER Class. �
(commencing with Section 7000)of Division 3 of the 6usiness DISTRICT NO. PROCESSED BY �
ond Professtons Code,ond my I�cense is in fuli force and effect. Power Apporotus 8 Lorge Appliontes �( � y•.
�� Q�' Size&Type HP,KW,KVA,or KVAR� j(,J • �t�6/1 � �
License Numberyl,�"�� Lia ClassC� Up 10 1 Ind. � F�NA� � V�
C��{,-.� Over 1 to 10 Ind. OATE � � VALIDATION �'
Conhacror `x+--�-r�� Dole� � Over 10 to SO lntl. � ���
OFINA
I om ezempl under Sec. Over 50 l0 100 Inc. BY /}i uVi I
B.BP.C.ior fhis reosen Over 100 t � y
� . - . Services,Sw6d.;MCC 6 Ponelboards � - � �- - �� � Z
Date: 0-200 Amp.Under 600 V
Signolure 201-1000 Amp.Under 600 V --�� � -- �
,� � Over 1000 Amp.or Over 600 V
�� � Exemplion for Reg.Moin1,Elect. ' �
�.
� l SINGLE FAMILY Tamp.Power�ole 8 Appur�enances �O�Q J F
�-• ,�J HOME OWNER-BUILDER DECLARATION Sign wiih One Branch Circuil - �e . o • •2 � ��
! •I here6y affirm ihot I am exempt from the Coniroctor's License Additional Sign 8ranch Cirtulis ��
Law for the following reason(Sedion 7031.5,Business and , � �3 6 5 2 7 �
Professions CodeJc - � � . .
❑ I,os owner of the property,will do Ihe work ond ihe Misc.Conduiis 8 Condutiors ' � � • •J U rJ,2 7� ,
structure is no�in�ended or offered for sole(Section O�her(See Complete Fee Schedule)_ .
7044,8usiness and Professions Code). � ► � O E�2 O�8 7
CONSTRUCTION LENDING AGENCY . � � -.
I hereby affirm Ihat fhere is a conslruction lending ogenty for
the performance of ihe work for which this permil is issued pERMIT FFE - (Sub-Total) � -. . - . _ �
(Sec.3097,Civ.C.). - �
' PLAN CHECKlNG FEE � . ..
Lender's Name � � -
� PERMIT ISSUING FEE .
tendei s Address � :
I cer�ify�hat I have read this opplicarion ond s�o�e that the TOTAL FEE � . _
obove informa�ion is correct.I ogree�o comply wi�h all Counry
ordinances ond Stole lows.regulaling Elecfrical wiring,and � . � � - �
hereby authorize�epresemaiives of fhis Counry to enter upon -
�he obove-me �ioned property for inspettion purposes. SEE REVERSE FOR EXPLANATORV LANGUAGE
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