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Home My WebLink About1132A (5) ___. � _.._.__ _ _ ._ __ _ ;___ __ _.--�_ ,..._._._ . __^______ j_� � - - -- � WORKERS'COMPENSATIONDECLARATION R0�0019DWJ3/B] APPLlCATION FOR ELECTRICAL PERMIT .O r �ifirm thot I have a cenificaie oi consent lo self `�EABpG (<<h y.u certifcota of Workers'Compensarion�nsu�ance, COUNTY OF l05 ANGELES ' DEPT.OP PUBLIC WORKS _�oi!�cerl�fied copy ihereof(Sec.3800,lah:C.) � � , +PolicyNo. Comppny• �_��._. FORA►PLIC�NT70FlllIN !06 �Cenified mpy is hare6y fumished. Naw Residen��ol Bldgs.&Pools EACH NQ FEE AOORESS � �❑Certified copy is filed w4h the covnry building insper � 1 8 2-Family,Sq.FI. 3 = E tOCAL17Y ' tion depanment. Mutri-family Sq.Ft. NeAkE57 ResidentialSwimmin Poo�s � cao555i. � Da�e Applicani� � OWNER FIRM NAME �� CERTIfIGATE OF EXEMPTION FROM WORKERS' � � �� COMPENSATION INSURANCE Outleu;Rec_Ligh_Sw._ ADDeESS First 20 � (TM�wctlon nwd nof b�compld�d if fh�work Involv�d hy Toial No. Additional CITY Tel.No. � � th�p�rmff b Fer en�Aundr�d dellars(S100J or I�ss.) . MnN CMECK 1 cerlify thol in;he performance of the work for which ihis AvpUCAM permit is issued,1 shall not employ ony person in ony mo ner �9h��0 Flx�ures . ' First ZO ADORESS so as to becoma subject to the Wo n'Compe tion w � Additional � �Dme -"�� . Apptica '..�' `-� � Toiol No. f CITY � � Tei.No. NOTICE 70 APPLICANT: If, afrer making ihis Cerliiicoie of� Fized Appliances Nat Over 1 HP vERMii Ecempiion, you should become subject to the Worken' �Range— Hea�er—O.W.— nvPUCATiOta Compensotion provisions of the La6or Code,you must forth- Oven —Oryer —W.M.— AD�RE55 with comply w'�R such provisions or ihis pe.mit shotl be 7op —FAU —W.H,— deemed revaked. ' � ' Hood —Fon —Other_ GITY Tel.No. IICENSED CONTRACTORS DECLARATION UCEHSE OR . Disp. _Room Air Cond _— Class. I hereby affirm that I am licensed under provis�ons of Chopter 9 REG.NUMBeR (commencing with Section 7000)of��vision 3 of the Business power Apparotus 8 large Appliances D�STRICT NO. PROCESSED BY a � and Protessions Code,and my licenu is in f�ll force ond effect. � - � Size 8 iype HP,KW,KVA,or KVAR /� O License Num6e� � Lia Closs � Up to 1 Ind. FINAL . �Over 1 to 10 Incl. DATE "'g_2�. O VAUOATION � Contractor pofe Over 10�o SO IncL � U ❑ FINAL I om ezempt under Sec. Over 50 l0 100 Inc. BY W 8.&P.C.for�his reason � Over 100 ' � Date: � Services,Sw6d.,MCC 8 Panelboords � ► � � Z I� . . - 0-200 Amp.Under bW V — .� 5gnolure 401-1000 Amp.Under 60D V , � ' Over 1000 Amp,or O�er 600 V �± � Exemption for 2eg.Maim.EIecL � . � <1 1 3 2 F � SINGIE FAMILY Temp.Pawer Pole&Appurtenances HOME OWNER-BUILDER DECLARATION � � 1 hereby affirm�ha�1 am eaempi from the Cantroctor's license Sign with One Bronch Circuit #�• • • • •z low for ihe following reoson(Section 7031.5,Business and Additional Sign Branch Circuits , � • .�3 Q 5� �� Professions Code): �I,as owner of the properry,will do ihe work and�he Misc,ConduNs 8 Conducton � • •�°3 Q$�� _ strutlure is not intended or offered for sale(Seclion 7044, ��her(See Comple�e fee Scheduley�, ► �0 a 2 5��S a Business and Professions Code). � CONSTRUCTION LENDING AGENCY ' . 1 hereby affirm ihof�here is a consvuction lend�ng agency far . . the performance of Ihe work for which Ihis permit is issued PERMIT FEE (Sub-Total) p�p y� � � , (Sec.3097,Civ.C.). . . � ' PLAN GHECKING FEE ' - Lender's Name 'j PERMIT ISSUING FEE � � Lender's Address TOTAL FEE � �Q � � I teriify thm I hove read this application and s�ore iho�the o6ove in(ormation is corred.I ogree to comply with all CouNy � � � , ordinonces and Siaie laws regula�ing Electriml wiring,ond � � .. • heraby au�horize represeNo�ives of Ihis County to enter upon . � • � - � th bove-memioned erty f ns ion purposes. ' ' ,,�(� SEE REVERSE FOR EXPLANATORY LANGUAGE ,_�� l'�4 S � �s gn re f P ee �— Date _ _: ,_.___-..� __. ,� _ - � , �. � � -- - APPROVALS� � OATE wSaecroa�s � - OIV�JER-BUILDER DEGLARATI�Iu=��'��``� SIGNATUR� � � � . , � . L'�' �� TEMP.�POWERPOLE � - . . - I hereby aflirm that I am exempt from the ConVactor's "` ' . . UNDERSLA6VJORK - � -� - � � Licens:Lawforthefolbwingreason(Section7031.5,Buslness r .. . , � . . � ROUGNCONDU(7 a(t andP�olessionsCodeJ.�Anycityorcounrywhlchrequiresapermil . , -� . 7o conslrucL altei.lmprove,demofish,or repair any shucture, _ ., ._ _ WIflING , �� ' � priorfo7lsissuance,alsorequirestheapplic3ntto�suchpc�mi[to' .' . PIXTURES, - � � � � � �ile a signeds!atement tha!he!s licensed pursuant fo tAo prov'r - - �� slons ol the Contractor's Clcense Law(Chapta 3{commencing� � POWER AU7HDRIZED . . . � with Section 7000)of Oivis.%on�3 0!fr,e Business and Prolessrons� � Code)or tha7�e!s exemp)fheretrom antllhe pasrs lOr fho a7fegetl l7TILINCO.NOSIHED � Cxempfion.AnyviolatronolSect;on70.?7.5byznynpplican7tora � FINAL G�ifer on�ronE Rermif su6(ects N;e aCFNcant fo a civi(pena(ty ot nd�morelhan - � - - - -'-- ' live hund�ed dollars(FSD01.�. NOTES - � � . . ' � � � � . � , � � � - - ❑I;as owner of the proDorty vrlll do the wOrk,and . ' the structure Is nat tntended ar ot(ered for sale. � f, . � . (Se:. 704a,Business ard Prolessions Code: The Corfracro�'s � UcenseLawCocsnofapp7ytoanownerofproAe�fywhobuildsor � , imp�oveslbereon,andwhodoessuChwwkhlmselfpiovidetltha! � � - sucb imprcvements me noi intentletl or oftered for sale,li. . . � . however,the buifdi��or improvement!s so'd within one year ol � compfetioqiheowner-0uiiCerwil�havethebmdenofp�ovingthat '� , , -� ho did nol buHd or rmprove/or fhe purpase o!salo.) �� I am exempt underSec. , 6&P.C.(orthlsreason Oate Owner _ '