HomeMy WebLinkAbout0900A (4) __ -
WORKERS'COMFENSATION DECLARATION ��� ���8� qpp��CATIQN FOR ELECTRICAL PERMIT �
\�ereby a�rm thm I have a certificare of consem to self C6806G
,1.��e,�or a certifico�e of Workers'Compensat�on Insuronce, COiNTY OP3L05 ANGELES BUILDING AND SAFETY
o,r q,c�rli ie�ly�ereof(Sec.3 ,Lob.C.) � �
�1.A�10.1� '
Ocy��o. Compon � � FOR AP►LICAM TO FllL IN JOB �
Certified copy is hereby furnished. New Residenlial Bldgs. o s EACH NO. FEE ADDRE
�-Certified copy is filed wiih Ihe county building inspeo- 1&T-Family,Sq.Ft.� s — ��CAIITY
fi �deportment. � Multi-fomily Sq.Ft. — NEnRESt
�(}���: Residenliol Swimming Pools CRO55 ST.
Date� ApplicaN�Y, . . . OWNER -
c� FIRM NAME
CERTIFICA7E OF EXEMPTION FROM WORKERS' Outlets:Rec�_LightS,Sw..[_ �`�'�'�� '
COMPENSATION INSURANCE r��� ' Firs�10 ADDrsE�S
(Thi�secflon nwd no1 bs cempivfed if Ih�work Involrad 6y Tota1 FioiLiL.1_ Additlonal CI Tel.N
Ihs permlf(s Fer ens hundred dellan(5100)or lesa.) .
I certify that in rhe performonce of�he work for which�his . � q���qNTK
permit is issued,I shall not employ any person in any manner . -
- so as to become subjed to ihe Workers'Compenwtion Laws. Lighting Fixlores First 20 ADDRESS
Tolol No. Addiiional
� CI1Y - Tel.No.
Applicant FiKed Applioncas Nol Over 1 HP PERMIT
s�NdTICE TO APPLICANT: If, ofter mpking ihis CerlHicale of APPLICANT
I, E.emplion, you�should 6ecome subjecf to the Workers' Ronge_Heoter_D.W._
Compensotion provisions of Ihe la6or Code,yo�must forth• Oven _�ryer —W.M._ AD^RE55 �C
with compiy wiih such provisions or this permi�shall be Top __FAU —W.H.—
deemad revoked. � Hood _Fan _Other_ CITY iel.N
LICENSED CONTRACTORS DECLARATION � � IICENSE OR � ��
I hereby offirm that I om litensed under provisions of Chap�er 9 Disp. _Raom Air Cond. — RFG.NUMBER Clos. �.
(commenting with Section 7000)of Division 3 of Ihe 8usiness DISTRIC7 NO. PROCESSED BY
- and ProFessions Code,and m licensa is in full force and effecL Power Apporotus 8 large Appliontes . �y� l >
��1�Yy /. Size 8 Type HP,KW,KVA,or KVAR� �O 1 ' {4\G �
License Number�'r�'�(J' Lic.Closs V� � - Up to 1 Ind. - FINAL -� - � V �
(`4 1�.� Over 1 to 10 Incl.� DATE yq��DATION � .
Conlraclor_i__ Date�_ Over 10 to 50 Incl' FI V
❑ I om exempl under$ec. Over 50 to 100 Inc. 8 . , �
8.8P.C.for this reoson Over 100 vf
� - - Services,Swbd.,MCC 8 Panelboards � - -� Z
Dale: 0-2qJ Amp.Under 600 V �
Signoture 401-1000 Amp.Under 600 V� � . � � -� � ��
❑ � Over 1000 Amp.or Over 600 V �,
Exemption for Req.Moint.Elett �
1 SINGLE FAMILY Temp.Powar Pole 8 Appurtenances �-��Q O A .
' - ' HOME OWNER-BUIIDER DECLARATION $i9n with One Bronch Circuil � +r`• ° • • •�
I hereby offirm fhat I om exempt from the Controcror's l(cense Addi�ion�l Sign Branch Circoits �
Law for�he following reason(Sedion 7031.5,Business ond � •3 p 5 9 6 .
Professions Code�: �
� Mlsa Conduirs 8 Conduc�ors � ' � •J C�9(7 r=_, �
I,as owner of the property,will do the work ond tha �
struc�ure is not in�ended or offered for sale(Secfion O�her(See Complete Fee Schedule)_ , ;
7044,Business ond Professions CodeJ.
aa2n�8�
� CONSTRUCTION LENDING AGENCY � � � � � ..
I hereby offirm ihot ihere is a mnstroction lending ogenty for
the per(ormonce of the work for which this permil is issued PERMIT FEE - � (Svb-To�al) �- � . �
(Sec 3097,Civ.C.).
- � - PLAN CHECKING FEE - � � � . .. ._...
Lender's Nome � �
�� � PERMIT ISSUING FEE ..
tendei s Address ��
� I cer�ify thor I have reod this application and sto�e thal the TOTAL FEE ' � �
obove infoima�ion is torreU.I ogree�o comply wi�h oll Couny
ordinances and Stole lows regulating Elecfrical wiring,-and . . �
hereby oWhorize representotives of this Couniy lo enler upon � � - �� '
�he obove-mentioned proper�y for inspection purposes. . . SEE REVERSE FOR EXPLANATORY LANGUAGE
c�xM� C�Q,�.� �'�''�E'�!l,{I�
Signature of Per �ttee - - ' Datd . . . .. .. ... . ��
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