HomeMy WebLinkAbout0596A WORKERS'COMPENSATION DECLARATION 76A663 �oiat �
� CE-806G APPLICATION FOR ELECTRICAL PERMIT
I here6y affirm that I have a certificale of consent to self insure,
oc a certi�icate ot Nrorkers'Compensatwn�nsurance,or a certi(ied •COUNTY OF LOS ANGELES BUILDING AND SAFETY
. copy the/reof 1(S�ec�.�j38�00.Lab.C.)
PoIiGy N0tiy1ZJCLC+Z�Cqmpdm�NOU S�JIfI� FOfl APPLICANT TO FILL IN "" JOB
❑ Certilied copy is.herehy furnished. �ND. New Residential Bldgs.&Po'^ EACH NO. EE AooRESS D -S �D G
. ' 1 8 2-FamilY,Sq.Ft.� � — � LOCALITY� _ �
�� Ce�tified�copy is tiled with the My 6uiWing inspection _ NEAFiESt
��tme�n��, Multi-lamily Sq.Ft. CR055 Si.
�Date���i o�a Applicant � ReSidential Swimming Pools OwNER OH
FIRM NAME
CEfiTIFICATE OF EXEMPTION FROM WORKERS' Oullets:Rec—Light_Sw.— � � �� // �/
� COMPENSATION INSURANCE � aooaess ,
(This section need not ba comp�eted if lhe wark Involved by lhe First 20 �
permil is for one huntlred dollars($100)or less.) Total No. Addilional CIT P Tel.No� ��
I cer[ify that in the performance of the vrork for which lhis permil � pp�i�K �
i5 i55ue4 I shall not employ any person in any manner so as lo
bewme subject to the Workers'Compensalion Laws. L.ighting Fixtures First 20 ADORESS ,
� Additional �
� � � • Tolal No. CITY- �- Tel.No.
Date APP����� Fixed Applbnces Not Over 1 HP pEqMiT
�;^TICE TO APPLICANT: If, after makiry �his Cer�ilicate OF pp�M.yNT// / C/�-���y ���
ption,you should become sublect lo the Workers'Compensation Nange_neaier_ u:vv. _
p�.,risions of the La6or Code,you mus[forthwith canply with such Oven_Dryer_ W.M._ ADORESS � ��
provisions or this permit shall be deemed revoked. Top _FAU _ W.H._
CIT /N �7O�' Tel.No. � � .
LICENSED CONTRACTORS DECLARATION Hood_Fan _Other_
I hereby aflirm Ihat I am licensed under provisions of Chapter 9 Disp. —Room Air Cond. _ uCENSE OH iQ/1p 9 , . �n/D �
(commencing with Section 7000)of�ivision 3 oF the Business antl FEG NUM6EH (/vi�3 �^
� Rofessions Code,and my license is in tull lorce and eflect. power Apparatus&Larga Appliances OiSTRiGi No. PROGESSED BY
�tj�l�A�,�,� /� /l Size&Type HP,KW,KVA,or KVAR ` v G� A-e O
License Number_–�YG�L Lic.Class�/`�� v Up to 1 Inci. � FINAL� U
C/�.,��N7�-- Date �!Q� Over 1 to 10 Incl. DATE O � �^ � �VALIDATION Q
� Contractor Over 10 to 50 Incl. F–
FIN L V
❑ I am exempt under Sec. Over 50 to 100 Inc. gy �
6.8P.C.for lhis reason Over 100 �� ��
Services,Swbd.,MCC&Panelboards � � �� �� R
�ate: p-200 Amp.Urdcr 600 V
Signature 201-1000 Amp.Under 600 V �0 5 9.b A
� � ❑ �� � �� � Over 1000 Amp.or Over 600 V � �• • . o 0 2
Exemptwn for Reg.Maint.ElecG
���� ��� �� � SINGLE FAMILY Temp.Power Pole&Appurtenances � • •9 2 9 0
� HOME OWNER-BUILDER DECLARATION Sign with One&anch Circuit
by affirm that I am exempt From the Conlractor's License Law • o 0 9 2.9 0�
e foliowing reason(Section 7031.5,Business and Professions Additional Sgn Branch Circuils
codeJ: 0&0 S—F3 8
❑ I,as owner of the property,will do the work and the structure Misc.Conduits 8 ConduCtors - .
is rat intended or olfered for sale(Section 7044,Business Other(5ee Complete Fee Schedule)_ � -
- and Prolessions Code).
CONSTRUCTION LENDING AGENCY - - - � - � �
1 hereby altirm that there is a construd'wn lentlirg agency for lhe �
performance ot the work for which this permi[is issued(Sec.3097,. . pERM1T FEE - - -(Sub-Totaq � . .
Civ.C.).
. PLAN CHECKING FEE . _.
Lender's Name /�
PERMIT ISSUING FEE
Lender�Address � ` ./`
I certif [hat I have read this applicalion and state�hat tho above TOTAL FEE U
informa[ion is wrrect.I agree to comply with all Counry ordinances
and State laws regulaling Electrical wiring,antl hereby authorize
representatives of lhis County to enter upon the above-menlioned � � -
pr fw inspectian pu�rpo�s�es. SEE REVEHSE FOH EXPLANATOflY LANGUAGE
�✓�l�Le 8� ��
Signature of Permittee Date
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