HomeMy WebLinkAbout1174A (5) WORKERS'COMPENSATION DECLARATION 76A663 ,o,e, . APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm ihat I have a certificate of consenl to self CE-806G
�ns��e,o�o ce.tificare of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,La6.G) �
P❑olicy No. Company FOR APPLICANT TO FILL IN DDRESS ,.J� ...+-�
Certified wpy is here6y fumished. New Residential Bldgs.&Paols EACH NO. PEE '
� Certitied copy is filed with!he munty building insper,- 1 8 2-Family,Sq.Ft. $ — S IOCALITY ° � ��
tion depn imenl� � - Muhi-family Sq.Ft. — NEAREST �
��'^ CROSS ST. ,y2%
Residential Swimmin Pools OWNER OR .1'�i_
Date �'���✓ A licant g
PP
FIRM NAME ��!t�
CERTIFlCATE OF EXEMPT N FROM WORKERS' � � MAi� j
Outlets:Ret_Light_Sw._
COMPENSATION�NSURANCE ADDRESS � p.n.at�-•7,.c.�--' . .
(This secTion need not be completed if the work involved by First 20 '1 ^
tha permif is for one hundred dollars(5100)or less.) Totol No. Additional CITY . y Tel.No. !�',� .
VLAN CHECK
I certify thaf in the performance of the work for whi<h this APPLICANT �;
permit is issued,I shall not employ any person in any manner
so as to bemme subjed to ihe Workers'Compensalion Laws. Lighting Fixtures First 20 ADDRE55
Totai No. Additionol ,
Date Applicant CITY Tel.No.
Pixed Appliances Not Over 7 HP PERMI7
NOT�CE TO APPLICAN7: If, afier making this Certifimte of � APPUGANT �7`�'
Exemption, you shauld become subjec� to ihe Workers' Range_Hea�er_D.W. _
Compensction provisions of fhe Labor Code,you must furth- Oven _Dryer —W.M.— ADDRESS
wiih comply wilh wch provisions or this permit shoil be Top —FAU —W.H. —
deemed revoked. �� . CITY - Tel.Na.
LICENSED CONTRACTORS DECLARATION Hood _Fnn _Other_
Disp. _Room Air Cond. — IICENSE OR 7 Class.
I hereby affirm fhat I om licensed under provisions of Chopter 9 REG.NUMBER [�� �. ����
- (commencing wlth Sedion 7000)of Division 3 of the B�siness DISTRICi NO. PROCESSED BY
and Professions Code,and my license is in full force nnd effect Pawer Apparatus&!arge Applinnces y
� Size&Type HP,KW,KVA,or KVAR j � ( (�j [{ '�.— Q'
O
License Number Lic.Gass Up to 1 Ird. FtNAL V
Over 7 to 10 Ind. �ATE� �'` � �� VALIDATION �
Contrador v �" Da�e _ Over 70 Io 50 Ind. � � �
❑ — 'FINAC
I am exempt under Sec 4ver 50 to 100 Inc. BY �� �
Over 100 � � `:'���'� �" '.
8.&P.C.for fhis reason y �.
Services,Sw6d.,MCC 8 Panelboards � , . � �
Dote: p_2pp Amp.Under 600 V
Slgnature 201-1000 Amp.Under 600 V �
Over 1000 Amp.or Over 600 V �
� Exemption for Reg.Maint.Eled. �� f:i;.. �
SINGLE FAMILY `' � �
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �� � 7.�i�i
Sign with One Branch Circuit ;
I hereby affirm ihat I am exempf from the Cnniroctor's License �,t• e ♦ • •7 �
Law for ihe following reoson (Section 7031.5, 8usiness and Additiono)Sign 6ranch Circuits
Professions Code): � • •G Tj,�j�
� � M,sc.Conduits&Conductors
�
I,as owner of the property, will do the work and the o s c. z- �
structure is nat intended or offered for sale (Sedian Other(See Complete Fee Schedule)— . °�J.��4 �
7044,0usiness and Professions Codej. p
o I OF.S`HJ� S
CONSTRUCTION LEN�ING AGENCY �
�hereby affirm that fhere is a consirucfion Iending agency for . �
the performance of the work for which this permit is issued PERM�T FEE (Sub-Total) �
(Sec.3097,Civ.C.). /'� � �
C—`' .L��/CJ PLAN CHECKING FEE �
Lender's NamP=�'��'°� � � �
(J PERM�T ISSUING PEE (f �' �
Lender's Address �
�certify fhqt I have read this applimtion and siate ihat fhe TOTAL FEE ���(� �
above information is correcr.I agree to comply with all Counry
- ordinonces and Siate laws reyuloting Electrical wiring, and � �
hereby authorize representatives of this County to enter upon - _ �
the above-mentioned p per or inspecti , purposes. SEE REVERSE POR EXPLANATORY LANGUAGE '
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