HomeMy WebLinkAbout1310A (7) WORKERS'COMPENSATION DECLARATION �� ��,a� APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affirm that I have a cerfifimte af consent to seif CE-806G -
fnsure,or a ce�tifitale�of Workers'Compensalion Insurance, � COUNTY OF LOS ANGELES . BUILDING AND SAFETY
or a certified copy ihereof(Sea 3800,Lab.C.) - � .
P❑olicyNo. Company FORAPVLICAMTOFILLIN - � ADDRESS � 4�� Qr� .
Certified copy is hereby furnished. New Residential Bldgs.8 Pools- EaCH NO. FEE
� 1 8 2-Famil FL f - — 3 LOCALIN r, - ..
Ce�tified copy is filed with ihe county building inspet- Y•54�
� tion department. - � � � Multi•family$q.Ft — NEAREST .
' ' �" � ' ��'� � , Resi ntial Swtmming Pools � pNmlSEROR L n�� ,�� �
Date ApplimM - . . S
0�0 O FIRMNAME t
GERTIFIGATE OF EXEMPTION FROM WORKERS' Outlats Rac_Light_Sw._ . r'ti0`�� j(�� /�
COMPENSATION INSURANCE ' . � aooRess- O � S lLs^ 0�1
Thts sxiton n�ad not b�com I�+�d if Ih�work involv�d F�rst ZO _
( P � Total No. CITY Tel.No.
th�p�rmit is fer ees hondrod dollars(SI00)er lets.) . Additional
PLAN CHECK �
I cenify that in the performance of the work for which this . - qpp���qryT � �
_ permif is issoed,I sholl not employ ony per n in ny monner . , _
so ae to ecome sobject to the W rke s'C�pe s on laws. li9hting Fixtores First YO ADDRESS - �
Addilional
� j� � � Total No. � CITY � - Tel.No.
Dafe � Vt pplicant '� " Fixed Appliances Not Over 1 HP ppq,y��i
NOTICE TO APPLICANT: If, oNer mo ng �s r fitat of � APPUCAM � r ns� "
Exemption, you sho�ld become subject to the Work i Range_Heater_D,W._
� Compenso�ion provisions of the lo6or Code,you must for • Oven _Dryer —W.M._ � AD�RESS a �V��Q
with comply wi�h such provisions or this permit sholl Top —FAU —W-H.— —
deemed revoked.. -- - � . � � -- CITY w�'n�'i' � ��4 Tel.No. - 1
Hood _Fan _Ofher_ -
UCENSED CONTRACTORS DECLARATION � � � . LiCENSE OR 't1
I hereby aHirm ihal I am licensed undar provisions of Cbapter 9 Disp. _Room Air Cond. — RFG.NUMBER "[`��� Class.�� ;
(commencing with Section 7000)of Division 3 of the Business power Apparalus 8 Large Appliances � DISTRICT NO. - PROCESSED BY �,
and Professionz Code,ond my license is in full force ond effecl. p,
Q� � Size 8 Type HP,KW,KVA,or KVAR- �d O
License Number��Uc Closs�! � Up�0 1 Incl. FINAL � � � � � V ,
�,�n, 1�qr /�� (� Over I to 101nc1. DA� YALIDATION O
Controctor OCf �l.(7�15'�'Date�� Over 10�0 50 Ind. FINAL l�J '
aI om exemp�under Set. � � Over 50 fo 100 Inc. 91' . . . . _ a -
B.8P.C.for ihis reoson Over 100 H �
� Services,Swbd.,MCC 8 Panelboords -"�- , � � ��- � - ?�
Dafe: 0-200 Amp.Under 600 V � �
Signature 201-1000 Amp.Under 600�V ' � � �
OOver 1000 Amp.or Over 600 V . . . .�
Ezemption for Reg.Maint.EIecL� � n � �!
SINGLE FAMILV Temp.Power Pole 8 Appurtenonces �/�� r�`fy g.1 31.O�A
HOME OWNER-BUIL�ER DECLARATION Gn��Q�
Sign with One Hronch Circoit .
I hereby offirm that�am ezempr from the Conrracror's License . #• •�� •�,��2
Law for the following reason(SeU�on 7031.5, Business ond Additional Sign Branch Circuitz �- . � - � -�
Rofessions Code): � . . � ��/��� I'�+3 Q rj-� '
❑ I,os owner of�he property,�will do rhe work and the M,sc.Conduits 8 Canducrorr � - � ' , �
structure iz not intendad or affered for sale(Section Other(See Complete Fee Schedule)_ ► , . ��:• •J Q Jr�O�
7044,Business and Prafessions CodeJ.
01.30-84
CONSTRUCTION LEND�NG AGENCY � � ��- �
I hereby a(firm that there is a consfrottion lending agency for ,
the periormance of Ihe wark ior whith ihis permit is issued PERMIT FEE � � (Sub-Tofal) -�-- - - --� - - -
(Sec.3097.Civ.C.). . . - . � .
� PLAN CHECKING FEE - � -� � -
Lender's Nome �
�� PERMIT ISSUING FEE - - � /� �
Lender's Address - '
I ce�tify�hat I hove reod this applicalion and state that the - TOTAL FEE _ ,.- �L��v _ .
obove information is correct.I agree b mmply with all County . . . -
ordinances and State laws regulating Eledrical wiring,and . � , _ .
hereby authorize representatives of fhis CooNy to enter upon . � - - -- �-� --
the abave-mentioned properry for inspedipn purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
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