HomeMy WebLinkAbout1381A (7) � � —WORI�RS'COM7EI�ATIONDECLARATION 76A663 ,o,B� APPLICATION FOR ELECTRICAL PERMIT }�
I hereby aHirm that 1 have a cerii/imte of consent to self �E'� .
insure,or a certifica�e of Workers'Compensotion Insuronce, � COUNTY OF LOS ANGELES BUIIDING ANO SAFETY L�
or a rti ie co �hereof Sec.3 Lo .C.)
. POoll y No. Compon ,�` � � .FOR A/►LICAHi TO FRL IN A DRE55 �C�.L � e �
Cerlified copy is hereby furn' d. Y y ew Residanliol Bldgs.8 Pools EnCH Np. FEE
�Certified copy is filed with c onry g inspeo- 1 8 2-Family,Sq.F. s — S �aAIITY
r�on d ��menr. � Mulfi-fOmily Sq.FI. — MEAREST �
Residenfiol$wimm(ng Pools CRO55 57.
Dale Appliconf . . OwNER OR
FIRM NAME
CER FICATE OF EXEMPTION FROM WORKERS' Outiets:Ret�Light_Sw._ N"q�� �
COMPENSATION INSURANCE � First 20 - ADDRE55 � .
(This��c}ion nasd no�6s coinpl�fad il 1h�work tnvolvsd by iotal No.� Additionol CIN tel.No
ehs permit f�for on�hundrad dollan(5700)or Ins.) ttnN CNKK
1 certify lhot in ihe performonce oi fhe work for whith fhis ' qpy���qNT . �
permit is issued,I shall not employ ony person in ony manner � � -
so es to become sobject to�he Workers'Compenwfion Lows. LigMing Fix�ures First 20 AODRESS -- '
� To1ol No. Addifional �
�ate 6pplimnt � CITY Tel.No. -
NOTICE TO APPLICANT: If, after making this Cerlifimte of Fized Applionces Not Over 1 HP . PERMIT �
Exempfion, you should became subjecf lo Ihe Workers' Ronge_,Hea�er_D.W._ _ APPI�G°`NT '((�(�k
Compenwtion provisions of�he lobor Code,yo�must fonh• , Oven _Dryer _W.M._ ADDRESS ( .{
with comply with s�ch provisions or this permil sholl he � Top _FAU _W.H.—
deemed revoked. � Hood _Fon _Other_ <ITY Tel.N . �
IICENSED CONTRACTORS DECIARATION .. � LiCENSE OR
� I hereby oHirm fhot I om litensed under provisions of Choplar 9 Disp. _Room Air Cond. _ REG.NUMBER � Ciaes. �,
(commencinq wiih Section 7000)of Division 3 of ihe Business power Appara�us 8 targe Appliances DISTRICT NO. PROCES BY }
ond Professions Code,and my license is in full fwce ood eHect. - � -�� d
Size��Typ�HP,KW,KVA,or KVAR� Q
Lice s vm r ic.Closs c" � hiw h'/y((�ti FINAt � �� � V
f-�y--,�J�,r,Up to 1 Ind. DATE ' (� OC
��9 -�.,/��c{ Over 1 to 10 IncL "'���� X VALIDATION . O
-Co t � Dare � il'-- ' " .
❑ -F�--f t Ovar 10 ro SO Incl. FiNAL r
I am e.empf under Sec � Over 50 fo 100 Inc. BY F.n � ai
8.8P.C.for Ihis reason � Over 1W ����<� L C J.Q� � � � y
. Services,Swbd.,MCC 8 Poneiboards � Z �
Doie: p_ppp Amp.Under 600 V
Signafure . 2b1-1000 Amp.Under 600 V � -�-��-� �
❑ � � � Over 1000 Amp.or Over 600 V - .
EKemption for Reg.MaiM.Elect.
SINGLE FAMILY - Temp.Power Pole&Appurtenonces .
HOME OWNER-BUIIDER DECLARATION Sign wirh One eronch Circui� �'� `j�� A
I hereby offirm Ihof I am exempt from Ihe Contraclor's licensa Addiiional Sign Branch Circui�s . R e e c o c 2�
Law for the following reason(Seciion 7031.5,Business ond .
Prc!cssions Codej: . � • o � Q 5 Q.
❑ �,as owner oi Ihe�properly,will do ihe work ond the Misc Conduits 8 Conductors- � �
shucture is not intended or offered for sale(Sec�ion O�her(See Complele fee Schedule�_ ► � � � � �G O`
7044,Business and Professlons Code). �2�3—8�1.
CONSTRUCTION LENDING AGENCY . .... .
I hereby offirm fhal lhere is o conslr�clion lending agency for
rhe performonce of ihe work for which ihis permi�is iss�ed PERMIT FEE (5�6-Tofal) �
(Sec.3097.Civ.C.).
� PLAN CHECKING FEE� � . ..
Lender'S Name � �
PERMIT ISSUING FEE
nder's Address � � � -
I erlify�hot have read this application and stale that the TOTAL FEE � �
ve in o� � n is correct.I ogree lo comply with oll County . . .
r inonces Sfoie lows regulofing Electriml wiring,ond -
e 6y au i repiesentalives of this ount to eNer upon . � �� , -
obove ned property ior inspe tion urposes. SEE REVERSE FOR E%PLANATORY LANGUAGE
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