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HomeMy WebLinkAbout1665A �KERS'COMPENSATIONDECLARAiION 7en6es ,o�e, qppLICATION FOR ELECTRICAL PERMIT � hat I have a certifieate of consent ro self insure, Ce•soaG ,.:FiCa2 of Workers'Compensation Insu�ance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY .,,,,,,y.�ereof(See.3800.Lab.G) Policy.No��Z S�A���pym FOR APPLICANT TO flLL IN ' ' " �8 �J�f �l ❑ Certified copy is here6y fumished. . . New Residential 01dgs.&Poots -EACH NO. . FEE Ao0r�e5S G��+� � � � 1 8 2-Famil S — 5 LOCALITY �\�l� �Certified�copy i5 fiied with t county buildi � inspettion Y���F�� _ � � partmen[ � Multi-lamily Sq.Ft. NEaaesT \ Residential Swimming Pools � � � pw,E�oi� �f �ate�l�'�7 Applicant _ . FlRM NAME q,. CERTIFICATE OF EXEMPTON FROM WORKERS' ' Outlels:Rec—Lght_Sw.— Mp�� r � �� ,COMPENSATION INSURANCE � - � ��� AODRESS. (Thle eacibn need not be comD��ed N the work invotved 6y the Frs[20 . permH It for au hundred dollars(57001 a ku.1 . Total No. Additional CIT � Tel.No. O I certi}y thdt in ihe�rforma�ca Of the work for which ihis permit � FPPLICANT K `Q is issued,I shali not employ any person in any mariner so as to �become su6ject to the Workers'Compensation Laws. , �L"ghting Fiatures First 20 ADDRESS � -� � Additional ,� � Tel.No.C�I �'O � � � � ' Total No. � CITY Date ApDlicant � Flzed Appliances Not Over 1 HP ' pEqMiT NOTICE TO APPLJCANT: If, after making ihis Certifica[e oF qr�iCnNi , Exemption,you shoNd become subject to the 1Vorkers'Compensatbn Range_Heater_ D.W. _ � provisions of the Labor Code,you must lortlnvith comply with sueh Oven_Dryer_W.M._ AD�RESS � �. .proviaons or this permit shall he deemetl reiroked. Top _FAU _ W H._.. . _ - CITY ���� Tet.No.�� ' O ' LlCENSED CONTRACiORS DECLARATION . Hood—Fan _Othcr_ `� . I.hereby alfirm that I am licensed under.provisions ol ChaPtef 9 uCEr.5G0l2 �7 (commencing wilh Section 7000)of Division 3 of the Business and - Disp. —Room Air Cord. _ rtEG.NUMeEtiOC �wss���� Prpfe55ion5 CAde,0nd rtly license i5 in full fofCC and efFe[t. ppWe�App3rJtU5&Lafge Appliance5__„ DISTRICT NO. PftOCESSED BY _1 , .... .. . . _ .. �+ - . _� 0� . . _ O.. ._ Y .. �+r�,, Size�8 Type HP,KW,KVA,or KVAR 0 License Nunmber�.�n�'T �f"c Lic.Class� . .�... -UP to 1 Incl:�."-.-. . .. . .- � FINAL/'f . �,�y F�,.�, . . ... . ..�..-. - U -Contrettor,L`�� N�• , Date ���_ �/ . _ Over 1 to t0lncl. � � �ATE�t-� YTJC/ yALIDATION Q i �r�i ❑ , Over 10 to 50 Intl. U FINAL I am ezempt under Sec. , Over 50 to_100 Ina _ _ gy _ . w B.BP.C.for this reason Over 100 . N' �� Services,Swbd.,MCC 8 Panel6oartls � � � �- ► � � � �� � - � Z �-� ��ate: D-200 Amp.Under 600 V � Signature -� -201--1000 Amp:Untler 600 V- -- - � - -�- ---- - ` - -- - � _� � -� � - � � � � Over 1000 Amp.oi Over 600 V Ezemption for Reg.Maint.Elect. - � -��� � SINGLE FAMILY���� � � Temp.Power Pole&Appurtenances �S HOME OWNER•BUILDER DECLARATION �� Sign with One Branch Circuit ��� G C.S� I hereby affirm that I am exempt irom the Contrador's License Law Add�tional Si n Branch Circuits tor the toilowirr�reason(Section 703 L5,Business anC Professions - 9 - � � - - -- -- - � � �� -- � �j n e . o-e 7 , Code�: ' � ❑ I,as owner ol the property,will do ihe xrork and the structure� Misa Conduits 8 Conducton - -• - -� � - - � � •-3 J b Q - is not inteMetl or ofteretl for sa�e�Section 7044,Business ��her(See Gomplete Fee Schedule)_ � e � ,- . and Professions Code�. � 'J`'?�=' CONSTRUCTION LENDING AGENCY �� - - � - � � � � - ��•� 5`H 7 I hereby afflrm ihat there is a construction lerdirg agency for ihe periormance of ihe vrork for which this pe�mit is issued�Sec.3097, pERM1T FEE � - -- ���� - (Sub-Totap ��S 0 d �•- ��- �--� - - � � � � - � � Civ.CJ. .. PLAN CHECKING FEE. _ _. . _ . ._ . _ . . _.. . ..._ ._ _ . • Lender's Name ' � PERMIT ISSUiNG FEE _ � _.. . _ _ (0 _ _ _ _ . _ _ Lender's Pddress � � I certify that I have read this appiication and state that the above_ , TOTAL FEE 3 S r SO ' .. . . . . ... .. ... ..._ . . .. information is correct.I agree to comply with all County ordina�ces antl State laws regulatirg Eleetrical wirirg,and hereby aulhorize� i rep�esentatives o1 this County to enter upon ihe above•mentioned � �� � ���� � - -�� --- � - � � �- -� - -- -� � � �"--�� '� pro ty for inspectio e . � �� ^'/��'�� .... - . . SEE REVERSE FOR EXPLANATORY LANGUAGE . . H` _ _ . Signature of PermRtee Date . � . . .. ..�. . . �.:..�. t_.�.,,- . �- --I -�� -- ;-,I-- ---.--- - -- -; - -- - : ,� � ; ; ,..- . � , -� � � �� _ '; ; �� ' '�-=� `=� ` i �--_. � '__., � ; .�, � � _ ; i i i I i :�-�.• i 1 �� : ' { - - jJ _ I '` �i' �' .�`�w !� � L' � i .- � - . ' � _ � - ��=�` . ,` ,_ � - . 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