HomeMy WebLinkAbout0912A `,WORKERS'COMPENSATIONbECLARATION so_omvovwa�e� �
1 �dA�� APPLICATION FOR ELECTRICAL PERMIT
, I here6y affirm that 1 hove a cenificate of consent ro self -cE.eroc
ifisure,or o certificate of Workeri Compensotion Ins�rance, COUNTY OF LO$ANGELES DEPT.OF PUBIIC WORKS
. or a tertified mpy thereof($ec.3800,Lab.C.) - '
. Po�icy No. Compony FOR AP/l7CANT TO Frtt IN JOB
. �CerGfied copy is hereby furnished. ' New Residenfiol 81dgs,8 Pools E/cH NO. FFE AODeE55
� �Cerlified co is filed with the count bui�din ins e[- 1 B 2-famil S Ft. E — 5 IOCALiTY
PY� Y 9� P Y, q�
tion departmenL - MuNi4amily Sq.F. — NEAREST
CROSS ST.
�ate Applicanr � Residential Swimming Po Is . �RM N� l'
. CERTIFICATE OF EXEMP710N FROM WORKERS' Outlels:RecLlight�'dF Sw.� ��� �/p �j
� - COMPENSAT�ON WSURANCE � � yJ73 � � nDORe55
Fint 20
. �(Thk sMlon no�d not bo compl�bd if fh�work Involv�d by Total No.� Additional CITY Tel.No.
th.p�rmN i�1er en�hundred dollors(5100)or I�ss.) � �Z plqN CHECK ,/� ��
I certify that in the performonce of the work for which this � � APPLICANT' �W 7 ����
�� permit is issued,I shall not employ any person in any manner �ighring Fixlores First 20 ADORf55 i flj(�+�
.so as to become su6jeU to the Workers'Compensation low. , �
/� Addi�ional
Total No._,(_C� CITY Tel.No.
Date��u$.._.Applicant Fixed Appliontes Not Over 1 HP PERMIi /� ,n A��
t",J�710E TO APPLICAN7: If, after maki this Certifi te f qppIICATION � KJ L��w'�Z
� nption, you should 6ecome su6 ct to the ork i Range— Hea�er��.W. —
. l.ompenw�ion provlsions of the Labar Code,yo� st f rth- Oven _Dryer —W.M.— AODRE55
' wifh comply w'th such provisions or this permit II be Top —FAU —W.N.— �
deemed revoked. Hood —Fan —O�her_ CITY Tel.No7
LICENSED CONTRACTORS DECLARATION lKeNSE Oa �
� D�sp. _Room Air Cond. —. REG.NUMBER' � Class.
I here6y affirm that 1 om licensed onder provisions of Chapter 9�� . �
(commencing with Sedian 7000)of Division 3 of the Business power Apparotus 8 large Appliances DISTRICT NO. / PROCESSE�BY a
� and Pro(e:sions Code,ond my license is in full force and effect.
� ] Siza&Type HP,KW,KVA,or KVAR � ' 0
�, license Number-`Y�Lic Class--i-V—�-- Up l0 1 Ind. FINAL � CC
� i\.���� Over 1 to 101nd, DATE � 0.LIUATION �
� Contractor �� Date� Over 10 to 50 Ind. FIN L ~
� ❑ I am ezempl under.Sec. O�er 50 to 100 Inc. BY W
Over 100 �-
. B.BP.C.for this reason . ► (n
� Servites Swbd.,MCC 8 Panel6oards �. � ' Z
� Date: �-200 Amp.Under 600 V � .
- Signoture 201-1000 Amp,Un er�p V ' � � �
� Ovet 1D00 Amp.or Over 600 V '�, ;
Ezemplion for Reg.Moint,Elect.
� SINGlE FAMILY � Temp.Power Pole 8 Appur�enonces
HOME OWNER-BUILOER DECLARATION -
..���>eby affirm that I om exempt from the Conimdor's License Sign with One Branch Circuit ,' z`0 9 L 2 A
.a for the following reason(Settion 7031.5,Business and Additional Sign Bronth Circuih �. � � �
Professions Code): � . , $}� �2
� ❑I,os owner of the proper�y,will do�he work and the Misa Conduits 8 Conductora , � + •��.5�
� stroc�ore is not intended or offered for sole{SeUian 7044, Other(See Complete Fee Sthedule� ► �
.Business and Professions Code). ` • ° •�G���_-'
� CONSTRUCTION LEN�ING AGENCY C�� (�—�8
� I hereby affirm�hot there is a constru�tion lending ogency for � , '
the performance of Ihe work for which this permit Is issued PERMIT FEE . (Sob-Totol) � � ��,
� (Sec.3097,Civ.C.). . . .
PLAN CHECKING FEE � � . , _
Lender's Name PERMIT ISSUING FEE � � f[� ;
lender's Addrass TOTAL fEE ' �
. I certify ihat I have reod this applicalion and itate thot ihe '
obove informmion is mrrect.I agree to comply wilh all Counly . '
ordinances ond Sta�e laws reguloting Electricol wiring,and � .
. hereb ao�horixe represenrotives of his CouNy to enter upon . �� ',
� ihe e-meni ned property for� speciion p poses. � -SEE REVERSE FOR EXPLANATORY IANGUAGE ��
. . . . , V � � . �i
Si ure ermitlee D e �
1
� � APPFOVALS �A7E � iNSPec7oR�S OWNER-BUILOERpECLARATION
.. , SIGNATURE . . - � - . - ��
. ,- ' - . ..- , � ' ` TEMP.PQWERPOLE _ . . ' . . ,
. I hereby af(irm that I am Cxempt from Iha ContractoYs
� - . UNDERSLABWORK � Licenselawforthofollowingrea;on(Secfrcn7031.5,&us/ness
-" - � ' � ' ROUGHCONDUIT � andProlessfonsCodeJ:AnycltyorcowrywAichrepuiresapermff �
•-•-- . ro construcG oltei,fm,piove,tlemolisA,or repalr eny sfmctu�e.
� � , � � WIRING�� � • priortoltsissuance,also�eqvhestneapplicantlorsucnpermitto
�''._ ' � �_:___ ..-,• .
� ' . � � - FIX7URE5 � . � file a signed statemenr that be Is licensed pursuant to 7he provF
�^,. '� � sfons o/the Contractor's License faw(Chap�er.9(commencing
. . � �POYVER AUTHORIZED � -' , � wilh Section 7000)ol 0ivision 3 0/the 8usin055 aod Prdessions
_ � - � Code)orihaihelsexemptthereframandthebaslslorlheafteged
.. � - UTILITYCO.NOTIFIED exemption.AnyviolationolSection7031.5byanyappficantlora
' . � � � FINAL � � E'f � �� � � � � , permit subjects the applicanr to a civil penafry ol n�f more fhan
n cr on ronf � � five hund�ed dollars($500l.:
. - , ...cNOTES .� ,. . . . � ,
- � • - �� � � ❑1,as ownerof the proporty wlll do the wo�and.�
� � iho 6tNcturo is not intonded or offered lor salo. i � '
, _, .. . , � � � - � � , (SeC.7p�i4,DusMess and Prolessions Code: The Con1r,,;ror's
, ��Llcenselawticesno7apA�Y�oanownerolpropertywhobuifdsor �
. . • i �.__ . . . , " � _ _� - . . � fmprovesthereon,andwho0oEs5uMwo�khlm5elfpiovidedtnaf
such lmprovements-nre not lntentletl a bNe�eC for safe. If,
� � � � � however.Mo building o�Impraverrent/s scld wlfhln one year ol
' compfefion,fheowrrer-0uiitle�willhavetha6urdenofprovMgthat
� - � �- . . . . ho did no'buifd or Jmp�ove for tne pwAose olsa.�e.J
t am exempS underSec , .
.. \
8&P.C.(or this reason
, Oato
Ovrner
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