HomeMy WebLinkAbout1396A WORKERS'COMPENSATIONDECLARATION 76A663 ,o�a, APPLICATION FOR ELECTRICAL PERMIT � .
I�hereby o{(irm that I have a certificale of consent to self CE-806G
ins�re,or a certificafe of Workeri Compensation Insurance, COUNTY OF LOS ANGELES BUILDING ANO SAFETY
�y�f�Jo�L�c.��(�ified copy�hereof(Sec.3 ,Lob. ) J11 �
P I� No�a I+I��Compon �• FOR APPIICANT TO FILL IN J08
OY Y . ADDRESS �RLD / GG
Certified copy is hereby f�rnished. New Residentiol Bldgs.8 Pools EACH NO. FEE �
�Certified topy is filed with the county building inspec- 1 8�-Family,Sq.FI. 5 = E LOCALITY
lion e fine 1. Multi-fomily Sq.FI. NEAREST
Residenfial Swimming Pools O NER OR
Date � APP��nN�A��dl6�f6��/ �
FIRMNAME- /
� CE IFICATE OF EXEMPTION FROM WORKERS �' ���
� � COMPENSATION INSURANCE Outlels:Rec_LigM_Sw._ qoortE55 E
Firs1 20
(Tbit s�clton nNd nof bs eompleted if tha work involvad 6y Tofol No. Addilional - CITY � . Ta _ 6 .
ths permit 1�for on�hvndnd dollon(5100)or I���.) P�AN CHECK '
1 terfify,lhaf in ihe performance of the work for which this APPLiCANi �
permi�is issued,I shail not employ any pe�son in any manner
so as to become subject lo ihe Workers'Compensa�ion Laws. lighring Fixtures First 20 ADDRESS �
�� . Tmol No. Addilionol CITY Tel.No.
Dote App��cant Fixed Appliances Nol Over 1 HP
NOTICE TO APPIICANT: If, after m6kin this Cer�iircote of PERMIT y� ,
9 APPLICAN (,GNB�CG f
E:emp�ian, you should become sabjed to 1he Workers' Range_Hea�er_D.W._ � ;
Compenso�ion provisions of Ihe Lobor Code,you must forth- Oven _Dryer —W.M._ AD�RESS ���� �• r�^
wilh comply with soch provisions or ihis permit sholl be 7pp _FAU —W.H.— .
deemed revoked. �� � . C�N.�/FL�13 L{� e�' ' ' � �
Hood _Fan _Other_
LICENSED CONTRACTORS DECIARATION .� � uCENse Ort
I hereby aHirm thot I am licansed under provisions of Chap�er 9 Disp. _Room Air Cond. — REG.NUMBfR - - CIau.0�
(commenting with Section 7000)of Division 3 of the Business power Apparalus 8 Large Appliances DISTRICT NO. /� PROCESSED BY }
��and Professions Code,and my license is in full force and eff t. � . / � 6. �
��� Size 8 Type HP,KW,KVA,or KVAR- Q
(icense Numbe�L(i�+5� Lic.Clos��"a FINAL � V
T Up�0 1 Incl. DATE ,� �
6'��qR L�u�QG �7 �i_p� _l.��' Over I to 10 Ind. I�;� �J� VALIDATION p I
ConlraUor J Dale_!-(LP�L_ Over 10�0 50 Incl. � �'
O FINAL � {,7
I am ezempt under Set. Over 50 to 100 Inc. 8Y W
L , �.
Over 100 y .
B.BP.C,for this reason � Z
Da1e: Servites,Swbd.,MCC 8 Panelboards � � � -
0•200 Amp.Under 600 V�
5gnature 201-1000 Amp.Under 600 V - � � � �
❑ Over 1000 Amp.or Over 600 V .
Exemption for Reg.Mainl.Elecl.
SINGLE FAMILY Temp.Power Pole 8 Appunenances z 1 3 9.6 A �
HOME OWNER-BUILDER DECIARATION Sign wiih One 8ronth Circuil �,.• • • • •2
I here6y ofiirm thot I om eaempt from�he Contrador's License Additional Sign Brench Circui!s - � --�
Law for the following reason(Setfion 7031.5,Business and �I,�': 1 7.5 Q �
� Professlons Code): � .
❑ I,as owner of ihe property,will do�he work and the M�sc.Conduits 8 Conductors � .• • •� 7,5 Q�
str�ct�ra is not in�ended or of(ered for sole�Section Other(See Complete fee Schedulej_ ,
7044,Business and P�ofessions Code). , -�7.��7�8 5 �
� CONSTRUCiION IENDING AGENCY � � � �
I hereby afiirm ihot there is a construcfion lending agency fo� - - �
Ihe performance of fhe work for which this permi�is iswed pERM1T FEE � - -� �Svb•Total) - -�
(Set.3097,Civ.C.). . -
- � � PIAN CHECKING FEE � � - � - �� � �
lender's Name � �
� PERMIT ISSUING FEE � � D ' .�-
lender's Address
1 cerlify�hat I have read this opplimlion and slole ihol Ihe TOTAL FEE . . � � _ .
above iniormation is torrec�.I og.ee to comply wi�h all Counry . ' _ �
ordinances and Sta1e lows regoloting Electriml wiring,and � . , . . _ . . _
here au� ize representatives of this County�o enter upon . � ' ,
the v entioned property 1or inspec�io purposes. .
� SEE REVERSE FOR EXPLANATORY LANGUAGE
gnalure of Pe�mittee Dale
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