HomeMy WebLinkAbout0884A WORKERS'COMPENSATIONDECLARATION �zo-ooroovwaie� qpp��CATION FOR ELECTRICAL PERMIT � .
. I hereby affirm thot I have a cerlificafe af consenl to self ����� .
insure,or a certificate o(Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT.Of PUBLIC WORKS
or a certifie•dn co y lthere�o�f��(S?y�-.3800},fL�ab.�.C.) � ��
PoliCy Nbv` v'`�^Company T"'��`�� FOR APPLICANT TO FILL IN JOB 1 y��
�Certified topy is hereby furnished. . . - 'New Residential Bidgs.8 Pools EnCH r7o. fee ADORE55 `� �f'1Y��
�Certiiied copy is filed with ihe co ty 6uilding inspec- I 1 8 2-Family,Sq.Ft. S — S LOCALITY
�ion epa ment . I Multi-family5q.N. — NEAaESi
�a I Residential Swimming Pools owN RSOR �I
Dote Applicant FiRM Na.nhE '
� .CERTIFICATE�OF EXEMPTION FROM WORKERS' I Outlets:Rec_Light_$w._ �`�� �
COMPENSATION INSURANCE i Firsi 20 ADDRE55 �
(This�aetton nkd nof b�compl�f�d iF th�work involvad by 7otol No. Addi�ional ��TY� Tel.No.
ih�permit ta!or one hundrod dollars(5100)or le�c.) PIAN CHECK �
�I certify that in ihe performance of ihe work for which this . qpp���q�
_ permit is issued,I shall nm emptoy ony person in ony monner . __
so os to become su6ject to the Workers'Compensation Laws. L79h1ing Fixlures First 20 ADDRESS
- Additional
Dare � Applicant Total No. CITY Tel.No.
NO710E TO APPIICANT: Ii, aiter moking thi:Certificata of Fixed Applionces Not Over 1 HP . pEpMiT
Ecemption, yau should become subject to the Workers' Range— Heoter—D.W._ APruCniiON
Compensation provisions of the Labor Code,you must forth• Oven _Dryer —W.M.— AD�RE55
wiih comply with such provisions or this permit shail be _ Top — FAU —W.H.— ..
deemed revoked. � Hood —Pan —Olher_ ��N Tel.No.
LICENSED CONTRACTORS DECLARATION - Oisp. _ Room Air Cond. — tICENSE OR
�hereby affirm�hat l am licensed under provisions of Chaptar 9 REG.NUMBER Closs.
(commencing wi�h Seclion 7000)of Division 3 of the Businezs power Apparat�s&large Appliances DISTRICT NO. PROCE SED BY � �
and Professions Code,ond my license is in full force and efFed. � � O :
Q ,.Size 8 Type HP,KW.KVA,or KVAR
License Number��`��� Uc.Cla �� � � Up fo 1 Incl. FINAL � V
Contractor"�" l��s Dole � t a Over 1 to 10 Incl. DATE �v,�L/e Q VALIDATION �
Q �Over 10 l0 50 Intl. FINAL O ,
I am exempt under Set. Over 50 fo 100 Int. gy , U
6.8P.C.for this reoson Over 100 � � ,
- - DO1e. � Services,Swbd.,MCC 8 Panelboords ► Z
, . 0-2C10 Amp.Under 600 V - —
S�g��+��•a 201-1000 Amp.Under 600 V
O - .Over 1000 Amp.or Over 600 V � •�=�`ci�?�il�. �
Eaemption for Reg.Maint.Elect.
SINGLE FAMILY - Temp.Power Pole,B Appurtenances �'� � � � ��
HOME OWNER-BUILDER DECIARATION .
I hereby a(firm thot I om exempf irom the CoMrocfor's License Sign with One Bronch Circuit � • •�r�5�
law for Ihe following reason(Setlion 7031.5, Business and Additional Sign Branch Circoits �
Professions Code): � . . • ' •�5.5�u
Miit.Conduits 8 Conducbrs
❑I,as owner of the property,will do the work ond the � ���2�—n� �
. sirudure is not intended or oifered for sole(Settion 70A4, Other($ee Complete Fea Schedule)_ ,
Business and Professions Code). - �
- CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for � � -
ihe perfo�monca of the work for which this permil is issued PERMIT FEE (Sub-Totol) ' �
. (Sec.3097,Civ.C.). � . . . . .
� PtAN CHECKING FEE � � �
lender's Name - - � �
� . � � PERMIT ISSUING FEE � �
Lender's Address � � � - � '
I certify that I have read this applitaiion and store that the TOTAL FEE �' ' ,
above informarion is correct.I ogree to comply with oll Coonty . . . .
ordinonces and Stote laws regoloting Eledrical wiring,and �
� here authoHze representatives of this County ro enrer upon �,
ih bove-men�ioned property for inspection urpo s. ' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat�re of Permittee �ie �'
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