HomeMy WebLinkAbout0910A WORKERS'COMPENSATIONDECLARATION maoieovwaie� APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affirm thal I have a certi(icate of consent to seli �Agp�y�
insure,or a certifitate of Workers'Compensation Insurance, � � �OUNTY OF LOS ANGELE$ DEPT.OF PUBLIC WORKS
or a certified copy ihe�eof(Sec.3800,La6.C.) �
Policy No._.--_�"'� Company FOR APPLICANT TO FILL IN JOB �
�Certified copy is hereby fumishdd. New Residenrial Bldgs.&Pools EACH No. FeE ADDrzE55 /
IOCALITY
�Cerliiied mpy is filed with�he coumy building inspec- 1&2-Family,Sq.FL $ — S A u
lion deporlment. Mulli-iamity Sq.Ft. — NEARFSr
CRO55 51. C r
Residenlial Swimming Pools OWNER OR
Da�e Applicont FIRMNAME I7l,� C lC '
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ret�light_�Sw.� ��� i
COMPENSATION INSURANCE � 13 G� AODRE55 �� -r/ I�<<r�'I��tC
First 20
(Thi�a«tion nead nof bo complefed if the work tnvolved by • CITY ��1 Tel.No.7/ i
� the permil fs for ona hundred doilars(f100)or In�.) To�al No.�_ Additional Vt/h N 4����— �
I certify ihot in 1he performance of the work for which this q pN[�p,NtK C�
permit is issued,I shall not employ ony pe�son in any manner �i9hling Fi:tures Fi�sf 20 ADDRESS
so as�o berome�su6jed to the Worke�s'Compensmion Laws. ,
� addilional
Date Applimnt , Total No. CITY Tel.No.
NOTICE TO APPLICANT: If, oiter moking ihis Certificate of Fixed Appliancez Not Over 1 HP pERMIT
Exempiion, you should become subject to rhe Workers' Range— Heoter—D.W. _ nP7tKATiON p
Compensotion provisions of the Labor Code,you mus�forth• Oven — Dryer —W.M._ ADDRESS
with comply with such provisions or this permit shall be 7aP _FAU —W.H.—
deemed revoked. Hood — Fan _Other_ CITY Tel.No.
LICENSED CONTRACTORS DECLARATION uCENSE OR
I hereby aNirm ihat I am licensad under provisions of Chaprer 9 �isp. _ Room Air Cond. � REG.NUMBER Class.
(commencing with Sedion 7000)of Division 3 of Ihe B�siness power Appa�alus 8 Large Appliances DISTRICT NO.. PROCESSED BY �-
and Profe:sions Code,ond my license is in full force and effect. � O
Size 8 Type HP,KW,KVA,or KVAR
Litense Number lic.Class Up to 1 Incl. FINAL� ^� V
Contractor Date �- Over 1 to l0 incl. DATE �u yp�IDATIDN � �
OO�ei 1010 50 Incl, FIN A I,� F"
1 am ezempt under Sec. Over SO to 100 Int. gy�/ \ V
B.BP.C.for this reason
Over 100 V� d
� Services,Swbd.,MCC 8 Panelboards � � N
�°�e' 0-200 Amp.Under 600 V �
Signalure I 201-1000 Amp.Under 60D V
O �- Over 1000 Amp.or Over 600 V .�'v 9 I.U fi
Exempfian for Reg.Maint.Elett.
SINGLE FAMIIY iemp,power Pole 8 Appurrenances �' ' • • • e?
'HOME OWNER-BUILDER DECIARATION �
I hereby affirm that I om exempt from�he Comrattor's License �. Sign wiih One 8ranch Circuit -,J e o<<l�j
law for the followinq reason I.Seclion 7031.5.Bosiness ond Addi�ional Sign Branch Circoifs �
Professi ns Code�: ' ' '�'���2��
I,as owner of�he property,will do ihe work and fhe Mist.Condoils 8 Condutlors a)�9_n�
struclure is not intended or offered ior sale($ecfion 704A, Olher(See Complete Fee Schedule)_ ,
8usiness and Professions Code).
CONSTRUCTION IENDING AGENCY
I hereby affirm that Ihere is a construction lending agency for
Ihe performonte of ihe work ior which this permil is issued PERMIT FEE (Su6•Tolal) • q 75 �
(Sec.3097.Civ.C.).
PLAN CHECKING FEE
tender's Nome 5 �
PERMIT ISSUING FEE �
Lendai s Address ' � � -
I terlify�hat I have reod ihis opplica�ion and siate that the TOTAL FEE ���
above informanon is co�recr.I agree Io comply wiih oll Counry .
ordinonces ond S�ale laws regulating Elechical wiring,and �
hereby ao�horize repr sen�a�ives of this County to eMer upon , , .
the e- ntione p;operty for inspeUion purposes. . .
SEE REYERSE FOR EXPLANATORY LANGUAGE
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