HomeMy WebLinkAbout1071AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure
76A663 10/81 APPLICATION FOR EL ®�J%�������j,J[�� T
CE -806G ���7-7T-V
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or a certificate of Workers' Compensaf su ance,� rtif
COUNTY OF LOS ANGELES
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Copy thereof (Sec. 3800.L ab. CJ �
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Policy No.._- COmparry
FOR APPLICANT TO FILL W
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copy is hereby furnished.
New Residential Bldgs. & Pools
FEEDRESSCertified
rtfd,c is filed with the c ntY 1 ction
de
1 & 2 -Family, Sq. Ft. — S
Multi-femily Sq. Ft.
LOCALITY
NEAREST
CROSS ST
Date Applica
NEACHNO.
Residential Swimming
OWNER OR
LG
"
CERTIFICATE OF EXEMPTION FROM WORKERS'
✓J
Outlets: Re�—iCLight Sw.
FIRM NAME
I MAIL
ADDRESS
- COMPENSATION INSURANCE E
(This section need not he completed I1 the work Involved by the
First 20
Total No. Additional
CITY
(/ �N.
Permit is for one hundred dollars ($100) or less.)
,I certify that in the performance of the work for which this permit
�"
PLAN CM
APFLICANT
. Is issued, I shall not employany person in any manner so as to
become subject to the Workers' Compensation Laws.
Lighting Fixtures First 20 - -
ADDRESS- -
-
'
Total No: Additional - -.
CITY
- Tel. No.
Date Applicant
Fixed Appliances Not Over 1 HP
PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
APPLICANT
/� 7
Exemption, you should become subject to the Workers' Compensation -
Range_. Heater_ D.W. _ -
-
provisions of the Labor Code, you must forthwith comply with such
Oven Dryer _ W.M, _
ADDRESs
provisions or this permit shall be deemed revoked. _
- Top FAU _ W.H.-_ "" - - -
CITY
Tel / Z%
. •LICENSED CONTRACTORS DECLARATION
-I hereby affirm that I am licensed under provisions of Chapter 9
Hood _Fan _Other_
Dis Room Air Cond.
0.
LICENSE OR /
REG. NUMGER
_ ._ Chss
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Power Apparatus 8 Large Appliances
DISTRICT NO.
PROCESSED B
Size &Type HP, KW, KVA, or KVAR
2
License Numb Lic. Class
-" Up to 1 incl,
Incl.
FINAL
DATE
OZ
l
V
_
Date
Over 1 to 10
/ p
- _
-. VALIDATION .
Contract
Over 10 to 50 Incl.
FINAL
U
- ❑ . I am exempt under Sec.
Over 50 to 100 Inc.
- By
" - -- - - - - LU
B&P.C. for this reason
Over 100
Z
Services, Swbd., MCC & Panelboards
- Date: "-
0 - 200 Amp. Under 600 V
Signature
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
❑-'
Exemption for Reg. Maint. Elect.
1 07. 1 A
- _ - SINGLE FAMILY
Temp. Power Pole & Appurtenances
..
_ #.• 's'• • 2
HOME OWNER -BUILDER DECLARATION
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law for _
the following reason (Section 7031.,,, Business and Professions
-AddiCional Sign Branch Circuits ---- --
fiai2550
Code):
El1. do the the
Misc. Conduits &Conductors
-
• �•! 25500
1, as owner of the will work and structure
I
rs not intended or offered for sale (Section 7oaa, Business
Other (See Complete Fee Schedule) _
- . 04.o5-89
and Professions Code).
►
CONSTRUCTION LENDING AGENCY-
-
- - - -
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit Is issued (Sec. 3097,
PERMIT FEE -- (Sub -Total)
Civ. C.).
PLAN CHECKING FEE -
-
- -- - - - - -
Lender's Name
PERMIT ISSUING FEE
Lender's Address
'—
I certify that I have read this application and state that the above
.TOTAL FEE _ .. ._ .. ....
'.. _.. ..._
Information is correct. I agree to comply with all County Ordinances
and State laws regulating Electrical wiring, and hemby authorize
representatives of this Co my to an. upon the hove- ntioned
propel -4y for Ins r 6ses.
- - - - SEE REVERSE FOR EXPLANATORY LANGUAGE
4 OF7
Signature df Permittee Unte
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