HomeMy WebLinkAbout0842A (4) WORKERS'COMPENSATIONDECLARATION ! �4wivovwaia� APPLICATION FOR FLGCTRICAL PERMIT O
I hereby offirm thai I have a cerlifimte of consent to salf�� �� .
insure,or a certificme of Workers'Compensation Insurance,i COUNTY OF LOS ANGELES � DEPT.OF PUBLIC WORKS
' or a certified copy thereof(Sec.3800,Lob.C.) ,
Policy No. ��� Company��h/a7x�" FOR APPLICANT TO Flll IN JOB 1 /1�
�Certified copy is hereby furnished. New Residential Bldgs.8 Pools EP.CH NO. FEE ADDRE55 • / �N•
�Certified copy is filed with the toumy building inspec- 1 8 2•Family,Sq.Fi. S — E LOCALITY ��� ti
tion depar�ment. � -� Molti-family Sq.FI. — NEAREST
����q Residential Swimming Pools OWNERSOR �""
Dote 1_.l�Lnpplicani�Am/4G���/r FIRM NNAEiG,,vcA G
CERTIFICATE OF EXEMPTION FROM WORKERS' _ Outlels:Rec—Light_$w,_ M`°'��
COMPENSATION INSURANCE nooRES N
This sactlon ne�d nof 6a com lefed IF Ihe work lnvolred b� First 20 CITY Tel.No.
( P P Total No. Addirional
' fhe pormit It for ono h�ndrod dollars(5100)or lass.) � . ptqN CHeCK
I certify that in Ihe performance of the work for which ihis nPvtiCnNT
permil is iss�ed,I shall not employ any person in any manner
so as to become s�bject to ihe Workers'Compensalion Laws. ��9hting Fixtures Firsl 20 ADDRE55
. Additionol
Total No. CITY Tel.No.
Date -� Applicani � Fixed Applionces Not Over I HP
NOTI:E TO APPIICANT: If, aftcr makin� Ihis Cerlifitole of PER1Y11T
. Exemplion, you should become su6ject to the Workeri Range— Heater—D.W. — r��:tl`v.i�GtJ
Compensotion provisions of Ihe Labor Code,yo�m�st forth- Oven —Dryer —W.M.— ADDRE55
wiih comply wiih such provisions or this permit shall be 7op —FAU —W.H.— ,
deemed revoked. Hood —Fan —Other— CITY Tei.No.
LICENSED CONTRACTORS DECLARATION � IiCENSE OR
DiSp. _Room Air Cond. _ REG.NUr..+eER �O j /Q CIo55. �
I hereby aifirm that I am licensed under provisions of Chopter 9
(commencing with Settian 7000)of Division 3 of the Business Power Apparofus 8 lorge Appliances DISTRICT NO. P OCESSEO Y a
and Professions Code,and my license is in full force and ef(ecl. 1 Q U
`' /� Siza 8 Type HP,KW,KVA,or KVAR
License Num�/ber 7 d���0 Lic.Class�2_ Up to 1 Incl. FINAI /�
�{n��� � Ir -31-c�o� Over I lo 101nc1. DAtE /�j�!/ VAIIDATION �
COnlroCtOr���K Dote_I Over 10 to 50 IncL � O
OFINAI
I am ezempt under Sec. Over 50 to 100 Inc. BY W
B.BP.C.for�his reason Over 100 � �
Date: � Services,Swbd.,MCC 8 Panelboards , Z
. 0-200 Amp.Under 60p V —
� Signalure 201-1000 Amp.Under 600 V
� Exemption for Reg.Maint.Elect. Over 1000 Amp,or Over 600 V �
�� SINGLE FAMILY Temp.Power Pole 8 Appurtanances s f
HOME OWNeR-6UIlDER DeCLARATION � - �
I hereby aftirm thot I am ezempi from Ihe Contractor's license Sign wilh One Bronch Circuit
Low ior tha iollowing reason(Seciion 7031.5,Business and Additionai Sign Branch Circuits .
Professions Code): ; �D�4.2 A
. ❑1,as owner of the property,will do Ihe work and Ihe Misc.Conduits 8 Conductors �• . . . .L
— str�tture is not intended or offered ior sale(Section 7044, Oiher(See Complefe Fee Schedule� ,
Business and Proiessions Code). � ` °2�J.5 U
� CONSTRUCTION IENDING AGENCY ,. � .���p�
I hereby afiirm ihat there is a tonstruction lending agancy for
the periarmance of Iho work for which this permit is iss�ed PERMIT FEE (Sub-Total) ��7 � � _&1 8
(Sec.3097,Civ.C.).
' - PIAN CNECKING fEE
Lender's Name � �
� PERMIT ISSUING FEE /Q �
Lender's Address _
I tertify thol I have reod ihis applicaiion and staie�hat Ihe TOTAL FEE
above informofion is correct.I ogree to comply wilh all Covnty � �
ordinances and S�oie laws regulating Eleclrital wiring,and >
hereby au�horize representotives of Ihis County to eNer upon � - �
Ihe above-mentioned roperty For inspection purposes . �
• SEE REVERSE FOR EXPLANATORY LANGUAGE ,
('�' ' ,�� �I/-P�' ,
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