HomeMy WebLinkAbout1034A �� WORKERS'COMPENSATIONDECLARATION �6A� �o�e� APPLICATION FOR ELECTRICAL PERMIT �7
I hereby atfirm thot I have a certificate of tonsent ro self CE�e06G `71
insure,or a tertifitote of Workeis'Compensenon Insurante, COUNTY OF LO$ANGELES BUILDING AND SAFETY ��
or a cer�Hied copy ihereof�Sec.3800,Lab.C.) ��
P❑olity No. ' Company FOR A►►IICANT TO Flll IN DDRESS /'
Certified copy is hereby furnished. New Residenfiol Bldgs.b Pools EACH NO. FEE
� Certified copy is filed with ihe county building inspec- 1 8 2-Family,Sq.P�. S — 5 IOCAIITY
tion deparlment. Mul�i-fomily Sq.Ft. — tvenee5i d �
CROS$ST.
Residential Swimming Pools
Date Applimnl � F�IRM NAME d
� � CERTIFICATE OF EXEMPTION FROM WORKERS' Ouflets:Ret�tight�t _$w.� ' �'''0'�� —
� COMPENSATION INSURANCE Firit 20 `JS .ZO -� ADDRESS �� G �
[Thb s�etioe n��d nef b�eemplatad iF Ih�work Involv�d 6y Totol No.� �Addi�ional r � - CIN�f � Tel. o. -�
fha pormi�Is for ons hvndrsd dolinrs(5100)or Ip�.J � GLAN CHECK
I cer�ify that in�he performance of the work for which thiz APPtICANT
— -permit is issoed,I shall not employ any person in any manner � —
so as to be ome subject to the Worker'Co ensalion Laws. Lighting Fiz�ures First 20 � ADDRESS � L( �
Total No. � Additional
8 �� � CITY TeI.No�'-�—��
Date pplicanl Fized Applionces Not Over 1 HP ffRM1T �
NOTICE TO APPUCANT; If, oNer moking �his Ca�tifimfe of APPtICANT
Evemption, you should betome subject fo �he Workeri Range_Heater—D.W._�
Compensarion provisions of the labor Code,yo�must forlh- Oven _Dryer _W.M._ ADDRE55
with tomp�y with s�ch provisions or fhis permif shail be Top _FAU —W.H:—
deemed revoked.- CIN Tel.No. .
. LICENSED CONTRACTORS DECIARATION Hood _Fan _Other_
Disp. _Room Air Cond. _ ���N�� Claas.
I hereby aifirm that 1 am licensed under provisions of Chopter 9 REG.NUenBER �
(cammencing wilh$ecfion 7000)of Division 3 of the B�siness ' � DISTRICT NO. PROCESSED BY n-
Power Apparatus 8 Large Appi7ances
and Professions Code,and my license is in full force and effect. J J O�
� . Sire 8 Type HP,KW,KVA,or KVAR� �� V
ticense Nomber lic.Cloas � y �
Up to 1 Incl. FINAL
Over 1 to IO lntl. DATE � �
Gonirotlor pote ..- � . VALIDAT�ON � �
OOver 10 to 50 Incl. FINAI ,�f � W
I am exempt under Sec. Over SO to 700 Irtc. BY /v / ' N
Over lOp F �
6.8P.C.for this reason �� Z �
" "�� � Dote: Services,Swbd.,MCC 8 Panel6oards � � _
0•200 Amp.Under 600 V
Signoture �01-1000 Amp,Under 600 V � �
Over 1000 Amp,or Over 60p V '�
� Exemp�ion for Reg.MoiaL Elect � �� O 3,A A
SINGIE FAMILY Temp.Power Pole 8 Appur�enontes
HOME OWNER-BUILDER�EQARATION Sign with One Branch Circvit �"'�� ' �2
I hereby offirm rhm I am exempt from the Controctor's License Additionol Sign Branch Circuifs
Law for Ihe following reoson(Section 7031.5,Buiiness ond �^ •�j���
�Profe �s Code):
U I,as owner of rhe property,will do the work and the Misc.Conduirs 8 Condoctors s e •j 2,��v
structure is nm intended or oflered(or sale(Section . Other(See Complete Fee Schedole)_ ,
(I 7044,Business and P�ofessions Code�. fl$.�� —8 6
I CONSTRUCTION IENDING AGENCY .
I hereby affirm Ihal Ihere is a construction�ending ogenty for �
the perfarmance of fhe work for which Ihis permit Is Issoed PERMIT FEE� � � �(Subdotal) �,f � � �
(Sec.3097,Civ.C.).
PLAN CHECKING FEE �
Lender's Name �
PERMIi ISSUING FEE �U � - �
Lender's Address
I cer�ify that I have read fhis opplimfion and sfa�e that the TOTAL FEE 3.2 (� ,
abave information is correct.I ogree�o comply wifh oll Covnry
ordinances and State laws regvloling Electricol wiring,ond ,. . . . . �
here6y uthor'ze repres ives of this Counry to en�er vpon
the ab e- ntion prope y ior inspec�ion purposGs.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
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