HomeMy WebLinkAbout1376A WORKERS'COMPENSATIONDECLARATION 76A663 �o,e� APPLICATION FOR ELECTRICAL PERMIT � .
I hereby alfirm�ha�I hava a certificate of consent lo self CE�B06G
�nsu.e,or a certificote of Workers'Compense�ion Insura�ce, COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,Lob.C.) .
V❑oli[y No. Company fOR AKLtCAM TO FILL IN ��� S
Cer�ified copy is hereby iurnished. New Residentiol Bldgs.8 Pools EACH NO. FEE /+DDRESS
� 1 8 2-Famil S Fr. a — E LOCALITY �
Certi(ied copy is fiied wi�h the county building inspeo- Y• Q�
� lian depo�lment. M�Iti-family Sq.FI. RO55 ST.
Date qpplicant Resid ntial5wimmingPools ' OwNEROR
� � (Jj1 FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' � Outle :Rec_light_Sw._ M`°'��
"COMPENSATION INSURANCE . ADDRESS �
Firsf 20
(This�acNon nesd not bs complefed if th�work inrolv�d b� Total No. Additional � CIN Tel.No.
ths p�rmif is for ons hundrad dallan(3100)er I�s�.) PLAN CNECK
1 certify�hot in the performance of�he work for which this , � qvPLiCAM
permil is iuved,I shall not employ any person in ony manner �
so os to betome subjeci to the Workeri Compenwtion Lows: Lighting Fiztures Fint 20 ADDRESS
Additional
To1ol No. GIN � Tel.No.
Da�e pplic 'ed Appliances Not Over 1 HP
NOTICE TO APPLICANT: after moking this Cer�ifi are of - q���GqM
Exemption, you should become subject �o the Workers' Range_Hea�ei_D.W._
Compensalion provisions of the labor Code,you musf forth- Oven _Dryer _W.M.— ADDRESS
with comply with suth provislons or this permit sholl be Top _fAU —W.H.— ��Ty Tel.No.
deemadrevoked. Hood —Fon _Oiher_
LICENSED CONTRACTORS DECLARATION � ���N�� Class.
I hereby offirm�hot 1 om licansed under provisions of Chop�er 9 Disp. _Room Air Cond. — REG.NUMBER
(commancing wilh Seclion 7000)of Division 3 oi the Business power Apporolus 8 large Appilances DISTRICT NO. � PROCESSE Y } .
ond Professions Code,ond my license is in full Torce and effect. �� 6. �
Size 8 Type HP,KW,KVA;or KVAR O
License Number lia Closs � Up to 1 Ind. F�N'°'� , V �
DATE �
Over 1 to 101nt1. VAIICATION �
Con�roUor Date Over 10 to 50 Ind. FINAL - V I
❑ I am exempt under Sec. Over 50 b 100 Int. BY " � W ,
a
Over 100 �
B.BP.C.for fhis reason' , Z
Dote: Services,Swbd.,MCC B Ponelboards "
0•200 Amp.Under 6W V
Signature 201-1000 Amp.Under 600 V �
OOver 1000 Amp.or Over 600 V ,y 1 3'�,(�A
Exemplion for Reg.Mainl.Elett. I U
� SINGIE FAMILY Temp.Power Po�e 8 Appurlenances � r r�I �� � � � �2
HOME OWNER-BUILDER DECLARATION 9 ��ly{ f�• •3 Q 5 0
. Si n wi�h One Branch Circuit
I hereby offirm Ihot 1 om exempt from the Controctor's license Additional Sign Branch Cirtuils
Low tor il�e following reoson(Secrcon:0�I.5, Business ond I . • • •3�,5 Q��,. '
Proiessions Code�: .
❑ I,as owne�of ihe ro er� II do�he work and ihe Mist.Cond�ils&Conduclors �
P P Y'W� 01her See Com lete Fee Schedule , �2�`�7�8 4
structure is not intended or oHered for sale(Section ( P �— � - - - - .
7044,Business ond Professions Code). �
' CONSTRUCTION IEND�NG AGENCY •
I hereby af(irm thot there is o construction lending ogen[y for
ihe peiformance of the work for which this permit is issued PERMIT FEE � (Sub-Totol) �
(Sec.3097,Civ.C.). �
PtAN CHECKiNG FEE � � �
tender's Nome
� PERMIT ISSUING FEE
lender's Address � . �
I certify that I have reod this applicalion and slate thot ihe TOTAL FEE . � . ���sD
above information iz correct.1 agree to comply wiih oll County
ordinances ond Stota lows�regulating Electrical wiring,and � .
hereby aulhorize represenlatives of thi:Co�nty lo enter upon
the a ove�men�ioned p�operfy for inspeciion purposes. . SEE REVERSE FOR EXPIANATORV LANGUAGE
Signolure oi Permi lee �— D 1�� .
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