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HomeMy WebLinkAbout1035A (5) WORKERS'COMPENSATIONDECLARATION �6A663 APPLICATION FOR ELECTRICAL PERMIT � � � CE�SOBG(2�80) I hereby effirm that I have a certiPicate ot consent to self COUNTY OF LOS ANGELES � �. � BUILDING AND SAFETY �� insure,ar a certificate of Workers'Compensation Insurance,or � , � . � a certified copy thereof(Sec.3800.Lab.CJ ' � �J��� c��,-��� � FOF APPUCANTTO FILL IN ' � J09 p/ -�. /�� �`�� � Policy No�..LLa?��L Compeny�a�•N" ADDHESS 0�! L - New ReSidential Bldgs.&Pools EACH NO. FEE � Certified copy is hereby furnished. _ 1&2Family,Sq.Ft. S — S LOCALITY ' � � Certified copy is filed with the county bullding inspectfan Multi-family Sq.Ft. CPOSS 5T � � depertment. . Residentia�Swimming Pools pyyNER OR ' � FIRM NAME Date � � � Applicant Outlets:Rec.�Light_Sw._ � MAIL� � First 20 ADORESS - � CERTIPICATE OP EXEMYTION FROM WORKERS' Total No.� Additional CITV - � T�I No.� � } '� COMPENSATION INSURANCE - - � O � . � PLAN CHECK ! (This section need not 6e completed if the WOfk Involved APPLICANT V �, by the permi[ is for one hundred dollars (5100)or iess.) Lightin9 Fixtures First 20 qDDRESS � � � Total No. � Additional � ��� I certify that in the performance of the work for which this Fixed Applianees Not Over 1 HP CI7� , T�I No. F- � permit is Issued,I shall not employ any perwn in any manner PERMIT � - W. '� so as to become su6ject to the Workers'Lompensetion Laws. Range_Hearer D.W._ � APPUCAN �- N � � � O�en _Dryer_W.M._ ADORESS O/, �� Z Date ADDlicant � Top _FAU _W.H:_ — Hood_Fan _Other_ dTY � �� Tel No. _ '� NOTICE TO APPLICANT:If,after making Ihis Certifcate of Disp. _Room Air Cond�_ UCENS .� ,�-y� ' Exemption, you should become subject to the Workers' REG.NUMBER .LJCGIan � � Compensation provisions ot the Labor Codq you must forth- pOwer Apparatus&l.arpe Appliances D15TRICT NO. . - PPOCESSEO 9V . with comply with such provisions or ihis permit shali be SizO&Type HP,KW,KVA,or KVAR / � deemed revoked. Up to 1 Inel. � � � `O ������ � � - FINAL� - Over 7 t0'IO InCI. OATE � VALIDATION , LiCENSED CONTRACTORS DECLARATION - Over 10 to 50 Ind. - - �`�-�1�—� . � I hereby atfirm that I am Iicensed under provisions ot Chapter Over 50 to 100 Inc. BY A� . �� . . ' 9 (commencing with Section 7000)ot Division 3 of the Husi- Over 700 � (,ti , ness and Rofessions.Code,a�d my license is In full force and . � ettect. Servites � � ', License Numbe Lia Cless�_� o-200 Amp.Under 600 V . � � � � . 207-7000 Amp.Under 600 V Contractor ate Over 1000 Amp.or Over 600 V � . ��. � � HOME 01i'NER•BUILDER DECLARATION Temp.Power Pole&Appurtenances . . - � � .. I hereby affirm that I am exempt from the ContractoPs Sign with One B�anch Circuit � � � . '�. License Law Por the fotlowing reason (Section 703L5,Husi- Additional Sign Branch Cireuitt � �. ness and Professions Code): . . � � . - . ' Micc,Conduits&Conductors' - �� ��`5 a ' � I, as owner of the property,will do the work and�the p�her(See Complete Fee Scheduiel— ��� � "#� �;� ���2 structure is not intended or offered for sale (Section _ . _ - � , � 7044,Business and Professions Code). - � . ' � CONSTNUCTION LENDING AQENCY � �I •�''9���� O �� I hereby nffirm that there is a construcaion lending agency � -�� � �� � . �, for the performance of the work fot which this permit is ' ,�1� ��9•� �� , - PERMIT FEE (Sub•Totaq .. issued(Se[.3091,Civ.C.). ' �� ��•L� b i 8�� � � Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) . � Lender's Address PERMIT ISSUING FEE � , � ' � 1 eertiry thet I have read this application and state that the TOTAL FEE . � �/� � , , above information is correct.I agree to comply with all County � � , ordinances and State laws regulating Eienrical wiring, and . � . hereby autb .e representatives of�his ly to�enter upon � , � . � � '�; the above en oned p p n� > urposes. � SEE'REVERSE FOR EXPI,ANATORY LANGUAGE ' � � � � I /Z/G �� ' Signature of mi ee . Date . - � � . � _ . - _ __ . .�� . a. . . � . . � : , . . ^ . . �. ,. r . - . . �. . . � .. ' ' � � � � � O�VNLR-I3UILDLR DECLARATION � - � . .. L'... c.��. . +-, � ' . .. . , i . " H. ._ . . . � . .,. , . ,,, � . �� � ;� _., ,__ . 1 hcrcby affirm'that I am ecempt From tl�c Contrsctor's � ..... ._._ .._...._ .... _ . .. _. ���� �qvaaova�s � '�'. on7e iNsaecToa�s � �.�.:� r ��,��� � ' License Law� for.tLe followin reason/Sec�ion 70J1.5, " - � � - -SIGNATURE ' ' � ' . . � - - �� ' -� , ' FJusiuess and-FYofessions CodeJ:��Any-�tity or cowuy ,�� �.. : . . . . . .. � — . ..- .. ..._. .._-��T[MP.PON.�ER POLE... ;---.;. ..._ -'-��--� � '� �'" � wd�icli mquires a pennrt to consrrtrct. alfer, fmprorc, .� . _.... �.���. �, ��,'��-'� Utvo'ERSI:a6 WORK.�. ....� ., � . �. � .. - . .;'�.. � .. � � derno(ish.or repair airy itruct�ve:Priar ro Its�rsruuncc, . • . - � -���- , � - a7so requbes dre app7ica{rt jo�rudr pernrit la jile a ... . - --�-�floucH corvout.r.; ,_..-� --;- --- - - ---� � �� � . srgrsed-statemeni thct 7te�is litensed.pnrtBattl m ilie ---��� - - ��- � - �' WiRIivG -� � ' � � provirionr af the Cantracior's f.icense l.aw(Chapter 9 . , . _._.._.(commencing K'tth Section 7000J�of Oirision 3 of die � ..._ . _ .. FIxTUf:Es-. - . - .----. - . �� � . . Biesiness a+��ProJession.c CodeJ nr t)mt he is exernpt .: � �.�.. .. ,. '._.. .__ .. ..._. _._ . : �. �\.. � . '�7heiefront and lJie'Laris for the alleged exeinpt/on.�4rr}. �,_. ._.._�____.... .._ .. PowEft au7Ho�rzEO-- � � vrola�im:of'SeUion 70i1.�5 byattyappficam fora permrt � UTIL�TI'CO.NOTIFIE�`_'� �'. ��� � Sub%ecls JJte apP��can7 fo a civil penalty ojnot more ll+an f.. _� � .. _ .-__ FINAL .. _ �-.��tiClt Mi 7�Wsa.__ , .. - .. .�. � � „1 ' �- ��� flte0`Iaaso�oncrr tsl�Oproperty�willdo�thc���ork.and - � ,,„ � � -� -- -- � . ,�tl�c struc[ure is not intended oc oftered to�sa1c. . .. , , � NOTES �.. -. , . . : . -.. . . . . . � � _....._ . _._....�-- .--..- - -__ . . - . , .. , . . . .� � 1Set. 70-04..IIun ess �rd Profersl s Code:� Tl�e C r� , , . �, , . . . . . 7� a on , o . � ' - � � � , ,; :� . „ � . ,,�tractnr's Licertsr Law docs no���apply�,m R�7 owner oJ . . � . , , property icho burlds or improves thereon,and wlro does .. ' . �� • . �. .,- .. "' �,� - .-., �.�.:•,.,�,. . , �. � . _ ... ' ' - .. � � s�ch worA trimselj pro��ided lhat such impro��ements .,,„ . , , , . - are rrot irvtended nr oJfereJ for sale. /f, Itowe��er,�1he � f � . --� ' -� ' . �� - ' i . � ' " � - ,building pr-imprOvemenl.i.s sold K�iti+in one,year.oJ �. .. . ........• ,v.`:.,...., .. ._ . • ,�._� :.. .. i ' , c npletion �11ie o ner 6uilder wr f are�dee u Jeri .� a ic 7 /: � br - . . - � . ' ..-,,oj�pro��ir�g�rlrar 1re drd rrot buiid or,.improve,/ar.the , , . . . . � purpose oJsalr.). . -� . . . , , i � , . . . . � .. , . . . I am excmpt m�der Sec. . - , � . _ _ � B&P.C.for tl�is reason : � __ - �---- --_ -.. . . � ' _ { . .. ..�. _.. . ._ _ .._ ' , , „ , - - i . , . -• Dnte i , . • ; , _.. _ _ O��ner ��'(1tF . ,_ ;__--- - , . _ , �: i , , _. . S. . • . . �, .. , � (C?. . . � -- - '_ . l_ ' .. ._ _ ---�_.___ _._ ._. ... __._ . . =ii ( �. • e . .. ._. - - � ,. . , . , i� . . ��-ar � i , . ; , _ - _ _ - , ,, .. _ . _ , , , � . . . . ,� .. •�