HomeMy WebLinkAbout1398A (7) , WORKERS'COMPENSA710NOECLARATION 7en663 +o�e+ qppLICATION FOR ELECTRICAL PERMIT {��
I hereby affirm that I have a certificate of consent to self insure, �68o8G
or a certificate ot Workers'Compensafan Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY u
copy therenol(Se�c.+3�8-�00,Lab.C.)
PoIiCy No����3�7Df7�OmPdny N FOR APPLICANT 70 FILL IN DDRESS S. �/VJ✓� / .
❑ Certitied ropy is hereby furnished. jN • New Residential Bldgs.8 Poo}�/��{/' EACH NO. FEE 0
� Certifietl copy Is filed with the counry building inspection 1 8 2-Family,Sq.Ft_LSQ`.2� 5 ' = S LOCALITY /e � - 5,�
art nt. ,/� Multi-family Sq.Ft. NehaEsi � �rA_
3 L. �- /� �n_ Residentiat Swimming Pools caOss SL L�f�L.,
Oate Applicant_f7�YTI 11�r�d-"-K.. � , Owr�E�i on A'
. � . FIRM NAM /�'
� CERTIFlCATE OF EXEMP710N FROM WORKERS' , qrt�ets:Rec—L'ght—Sw._ ���
- COMPENSATION INSURANCE . ' , nooaES �O�� "'
�ThIs seetbn need not 6e oomp�eted if the work involvetl by the First 20
permit la for one hundred dollare($100)or less.) Total No. Additional CITY Jr/� � �a Tel.N�'.. •,x
I certify that in the performance of the work�for whiCh this p2rmit I'V N CHECK
is is3Ued,I shall not employ any person in any manner so fls to APPLICAN7 �
— become subjett to the Worke�s'Compensation Laws. L'ghtinq Fixtures First 20 ADDRESS � ' - -
� Additional
� � To[al No. CITY �� Tel.No.
Date Applicant fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: �F, a(ler making this Certificate of PERMiT ���i �/�,�� � _
E-=mption,you should 6xome subject to the Workers'Compensatbn Range_ Heater_ D.W. APPLtCnM / (/
. �.ions of the Labor Cotle,you mvst forthwith comply with such Oven_ Dryer_ W.M._ A�DRESS .Q ��
�p,_dsions or this permit shall be deemed revoked. Top _ FAU _ W.H._ ��Ty ��l � 7ei.Na �// �
LICENSED CONTRACTORS DECLARA710N - Hood_Fan _ Other_ /"'� �G7��
I hereby affirm that I am ficensed under prwisions of Chapter 9 _ Disp. —Room Air Cond. _ uCErvSE oH • � ��_/y�
� (commencing with Section 7000�of�ivision 3 of the Business ard AEG.NUMBER z•
Pr0}e55i0n5 COdC,arM my IiCBn50 i5 Ifl}ull 10fCB 8nd etfeLt. DISTRICT NO. OC D �
Power Apparxtus 8 Large Appliances
L�ense Number ��27 Lia Class �-V Size 8 TypeUp to iVl cl.a or KVAR FINAL `� �- - -
,��-�'y";} ��,/ q7 Over 1 to t0lncl. DATE !� �
�ConiraclorN'�`����r Y�V Date • v � - �'�V y VALIDATION 0 . �
Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. By W
B&P.C.1or this reason Over 100 � N�
Services,Swbd.,MCC 8 Panelboards - � � . Z
� � � Date: 0-200 Amp.Under 600 V �
Signature 201-1000 Amp.Under 600 V � . .. c�1 3 9 8 A
❑ � - - - � Over 1000 Amp.or Over 600 V '
Exemption for Reg.Maint.Elect. �� � � •L�
�' SINGLE FAMILY� � Tem Power Pole 8 � ° �7�8 2
p. AppuAenances
HOME OWNEF-BUILDER DECLARATION � Sign with One Branch Circuit �� � � � �9•���'�`��'
I hereby alfirm tha[I am exemp[Irom ihe Contractor's License Ww
f� -'+,e following reason ISection 7031.5,Business and Professions - Addi!ionat Sign Branch Circuits . ^ '����
� `F
� � �� \
�� ❑ I,as owner ot ihe property,will do ihe wo�k and the structure Mise.Conduits 8 CorMuctors � � � � � � .
is not intended or offered for saie(Section 7044,Business aher(See Complete Fea Schedule)_
�� and Piofessions Cods). ' - � � , - - � -� �
\
CONSTRUCTION LENDING AGENCY � _
\•mby affirm that thera is a construction lending agency for ihe
kmance W the work for which this permit is issued(Sec.3097, . PERMR FEE � - -�- -- -� -- (Sub-Total)�
��.
PLAN CHECKING FEE
�Name
PERMIT ISSUING FEE �
�tldress � - � � � �
nt I have read this applieation and state that the above TOTAL FEE ��
�is correct.I agree to comply with all Cwnty o�dinanees � - � � �
�aws regulating Electrical wiring,and here6y authorize
�es of this County to enter upon the above-mentioned ' � - � � � � �� -
inspection purposes. � �� SEE REVERSE FOR EXPLANATORY LANGUAGE
.�.�/�.��
,f Permittee Date
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