HomeMy WebLinkAbout1399A (7) . WORKERS'COMPENSATIONOECLARATION 76A663 �a�8� qppLICATION FOR ELECTRICAL PERMIT �
I Fr,�e6y aflirm that I have a certificato of consent to selF insure, CE-eo6G
or a certiticale ot workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING ANO SAFETY
copy thereoF(Sea�3+8�y00,1ab.CJ �) .
PoIiGy NO`�rjjS��t��pmpd�ly {� L�.S//�-I/I'�- FOH APPLICANT TO FlLL IN � ' .bg !
❑ Certif'ied copy is hereby furnished. �/y�. New Residential Bidgs.8 Pools EACH NO. FEE . ��AESS J•Jv�vej� C, ,
� �� g = g , y LOCALJTY � � �'� '
Certified copy is filed'with the county buildi� inspection 1&2-Family,Sq.Ft.
f(me 1. �� Mul�i-family$q.Ft. NEAREST
�f Residential Swimming Pools � p,,,�Eq R /],
Date���APPIiCant �(TP .. � FlRM NAME/�` �-
� ' CERTIF�CATE OF E%EMPTION FROM WORKERS' � . � �� hui�
Outlets Ree—L'ght—Sw.— ,v. �a
� �� - ��� COMPENSATION INSURANCE � � � � � � nDDRE55
.(Thls sectbn need not be completed it the work irnolved by the First 20
� pe�mit ia for one hund�ed do1Wrs(5100)or less.) Total No. Additional� CITY �� Tel.No.
I ce�ti}y that in tha performance of the work for which this permi[ . � . � P�CnECK
is issued,I shall not empby arry person in arry manner so as to � ����M _
— become su6lett to the Woilcers'Compensation Laws. . Lightiry Fixtures First 20- ADDRESS � �- � .
� ' ' � Total No. Adtlitpnal .,. GTY � Tei.No.
Date APplieant � ' ' Fixed App�iances Not Over 1 HP PERMIT rA
NOTICE TO APPLICANT: If, alter makirg ihis Certificate of APPLICANT�� � L.
F•�^Tption,you should 6ecome subject to the Workers'Compensation .Range_Heater D.W. _ _ �
� �ons of the Labor Code,you must forihwith compiy with such Oven_ Dryef_ W.M._ ADDRESS �v. �
, p�..d�s�ons or this permit shall be deemed revoked. .. Top� _ FAU _W.H._. . . ... .
•�- � . LICENSED CONTRACTORS DECLARATION � Hood_ Fan _Other_ qTY �/LL� �Tel.N /�f� �
�.I hereby affirm that I am licensed untler provisions�oF Chapter 9.. Disp. ._ Room Air Cond. — uCENse oa ���g./r/�
(commencing with Section 7000)of Division 3 of the 8usiness aM REG.NUMOEFi (�
Professions Code,and my license Is in tull lorce and effect. . D�S7RiCr No. P ESSE
Power Apparatus 8 Wrge Appliances � . .�. . _. �:
�� � C I U Size 8 Type HP,KW,KVA,or KVAR Q
License Number Lic.Class - Up to 1 Incl. � FINAL � ���
Contractor��UR�Cl� Date � � - �r 1 to t01nd. DATE t�'�..c� ,YALIDATION � �
Over 10 to 50 Incl. FlNAI V
❑ .I am exempt under Sec. Over 50 to 100 Inc. BY � . . W
B,&P.C.for this reason Over 100 �
�. _ . ..."-.. . . . . . Date: Services,Swbd.,MCC&PanelboartJs..- .-. . .. , � Z
0-200 Amp.Under 600 V n 1 3 q
Signature 201-1000 Amp.Under 800 V ��� � -� � - ' � � �������
� -- � � � � Oaer 1000 Amp.or Over 600 V �9.Q���
❑ Exemption for Reg.Maint.Elett. - � � � - - �� [� � �
�� ���� - � � SINGLE FAMILV �- � . Temp.Pow?r Po!e&Appurtenances _ . . � .
HOME ONRJER-BUILDER DECLARATION Sign with One Branch Circuit -
I hereby affirm that I am exempt trom the Contractor's Licenso Law I`��
� e(otiowing reason(Section 7031.5,Business and Professions Additional Sgn Branch Circuits - �
�:
❑ I,as owne�of the property,will do the wo�k and Ihe siructure Misa Condui�s 8 Conductors : � - -
is not intentletl or olfered tor sale�Section 7044,Business Other(See Comptete Fee Sehedute)_
and Professions Code). ,
GONSTRUGTION LENDING AGENCY - �
I hereby affirm that there is a construction lending agency for the �/�
performance of the work for which this permit is iswed fSec.30�37, PERMIT FEE �� (Sub-Totap � � - � � �
Civ.C.). , �
PLAN CHECK�NG FEE � � - -
Lender's Name O
�- �PERMfT ISSUING FEE� -
Leider'9 AddreSs � � .�
I certiry that I have read this application and state that the above 70TAL FEE ._ . _ . �
information is corred.I agree to eomply with all County ortlinances
and State laws regulating Eiectrical wiring,and hereby authorize . . , . . -
representa[ives ot this Coun�y to enter uDon the aboVe-mentioned . �
prope� for inSpeCtion purposes.
�� � „ � / � � �� -� SEE REVERSE FOR EXPLANATORY LANGUAGE � �
��'L
Signature ol Permittee Date
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