HomeMy WebLinkAbout0945A 0946A WORKERS'COMPENSATIONDECLARATION �aA�� ,o:e� APPLICATION FOR ELECTRICAL PERMIT �
I hereby offirm ihot I have a car�iiicate ot consent to self � CE-806C .
ins�re,or a certificate of Worke�s'Compensation Insurante, COUNTY OF LO$ANGELES �l[)Ipl SA �i�
or a certif'e opy t er�eQ�f c ,Lob.C.) - � `
Policy N� Z� �"Compa� FOp APPIICANT TO FILL IN JO � � ,� wr1 .
� Certified copy is hereby furnished. EACH NO. FEE A�DRESS //�i. ,
l� New Residenliol Bldgs.8 Pools �uGY ,
p�� Certified copy is filed with�he munty building inspec- 1&2-Family,Sq.Ft. E = E LOCALIN
/`�' tian d partment. � � �� J Multi•(omily Sq.Ft. � . NEnREST
� ^t' /�y� Residen�iol Swimming Pools C2055 ST.
Dare Applicant ��_�_��, OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' putlets:Rec_Ligh�_Sw._ 6
COMPENSATION INSURANCE � F.fS�� . DDRESS
(Thfs seclton�na�d nol b�eomplat�d if the work inrolrad by Total No. Additionol CITY Tel.No�
tha permif is for one hundred dollan(5100)or leas.)
I cerlify that in the performonce of the work for which this PL.4N CHECK
APPIICANT
permit is issued,I shail not empioy any person in any manner
so os to 6ecome subject ta 1he Workers'Compensofion Laws. Li9hting Fixlures Fir51 20 ADDRE55
� � Tolol No. Additional
<ITY Tel.No.
Date Appliconl Fixed Appliances Nof Ove�1 HP
NOTICE TO APPlIG4NT: If, oTter moking this Cartificate of PERMIT ��
Exemplion, you sho�ld become subjett to the Workers' Range_Heater_D.W.— APP�iCANT
Compensaiion provisions of the labor Code,you most forth- Oven _Dryer _W.M._ � ADDRESS �� �S"�' -
with comply wilh suth provisions or this permit sholl be Top _FAU —W.H.—
deemed revokad. � Hood _Fan _Other_ � CITY Tel.fJo. �
� UCENSED CONTRACTORS OECLARATION uCENSE OR �
I hereby oHirm thot I om licensed under provisions of Chapler 9 Oisp. _Room Air Cond. _ REG.NUMBER � � Closs.�� ,
(commencing with Setlion 7000J of Division 3 of the Business power Apparatus 8 lorge Appl�onces DISTRICT NO. PROCESSED BY
and Professions Code,ond my lice e is in full force and eHect. . Y
/7� Size 8 Type HP,KW,KVA,or KVAR l O ,�u�tip� �
License Number Lic Closs �� Up to I Ind. � - FINAL O �
�('' Over I to 101nc1. DATE � � D�/ p�
Controctor Da�e "v � � O `7` VALIDATION 0
Over 10 to 50 Ind. FINAL V
❑. I am eKempl under Sec. .Over 50 fo 100 Inc. BY O " a
� B.BP.C,for�his reason �9Q��� �n
� . Services,Swbd.,MCC 8 Ponelboards ' ► . �0 9 4 5 A ?
Date: 0-200 Amp.Under 600 V �
#�.� • • .2
Signature 201-1000 Amp.lJnder 600 V � .
❑ Over 1000 Amp.or Over 600 V �
Exemplion for Reg.Maint.Elect. �'� �3$7�
SINGLE FAMIIY Temp.Power Pole 8 Appurlenances ��� �3�x 7�c=.i
HOME OWNER-BUILDER�ECLARATION Sign with One 8ranch Circuil '
I hereby affirm that I om eKempt from rhe Contracior's License 0�.� �—$Q
Low iar the follnwinn rnn n lS..ninn 7f191 5 a�..��e....,..t Addilionol$ign Branth Circoits
cn ._._ _ . ,,.__'.._
Pro(essions Code): y � � � -4�C)Q,6 A
❑ I,as owner of the properly,will do Ihe work ond the M,sc.Conduils 8 Cond�ttors � � �•: ••. •2
s�ruUure is nof infended or offered for sole �Seclion Other(See Complete Fee Sthedule)_ , .
7044.Business and Professions CodeJ. � •3 3 Q 0 0� �
CONSTRUCTION LENDING AGENCY '3 3 Q 0 0=
I hereby oifirm that�he�e is a construction lending ogency for c.�
1he performance of Ihe work for which Ihis permit is issued pERM1T FEE � (Sub-To�al� •
(Sat.3097,Civ.C.). - ��,� �—8�l
PLAN CHECKING FEE � ,
lender's Name �
- PERMIT ISSUING FEE ._ , _ l' ,
Lender's Address �j( � ' ��
I certify�hot I have reod this applica�ion and stote Ihal ihe TOTAL FEE (t �
above information is correU.I agree lo compiy wi�h all County
ordi es and Sto�e laws re oting Electrical wiring,and � '
her authorize repre n! v of ihis County�o enrer opon � � ,- � - �
t ove-men r y for inspec��on urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
5 ture of Permiv e Doi� �� �
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