HomeMy WebLinkAbout0711 (4) .ERS'CO�IPENSATIONDECLARATION 76a663 APPLICATION FOR ELECTRICAL PERMIT - � �
CE�806G f2-80) .
irm tha� � have a certificate ot consent to seif COUNTY OF LOS ANGELES � BUILDING ANO SAFETY
certificate of Workers'Compensation Insurance,or _
:tor•S �py thereof(Sec.3600,Lab.C.) � '
TJ,S 1+�(AI� �'1,1 �. 'FOR APPLICANT TO FILL IN JOB ''"�� �
'��rt� k+--�=�1"�ompany 72T1"'� ADDRESS �` J� Q_l" 1._
- � ' New Residential Bid9s.&Pools EACH NO. � FEE
���' fed cnpy is hereby furnisheJ. 1&2-Family,Sq.Ft. S — 5 LOCALI7Y � � � �
�prr, � N Aq T '
��° I;ied capy is�led with the county building Inspection Multi-family Sq.Ft. CFOSS S7- �, •
«�� rtment � . Residential Swimming Pools OWNER OR }. � -
>F� :�A_[s' . �� � FIRM NAME L�� �
1/1� i j���A Iicant �+ � MAIL -
PP Outlets:Rec..�Light_Sw._
�nr � . • FirSt 20 ADDRESS
��r�, '.TIFICATE OF EXEb1PTION FROM WORKERS' Total No. Additional CiTY 7ei No.
,�r�� � CO!�1pENSATION INSURANCE , PLAN CHE K d ,
rp�r � � � . . AVPLICANT �
;:ction need not be complcted if the work involved Lighting Fixtures First 20 � V
�� permit is for one hundred dollars(5100)or IessJ ADDRESS
Total No. Additianal �
.ify that In the performance ot the work for which this pixed Appliances Not Over 1�HP CITY � Tel nlo.. � O
"�'t is issued,1 shall nnt employ any person in any manner . pERMIT /�� V
�'�o become subJect to the Workers'CompensaHon Lmvs. Range_Heater_�.W._ . APPI.ICAN L +i17 41
%� Oven _Drye�_W.M._ ADDRESS O��G�„ [n
tt � pPr��cant Top _FAU _W.H._ � ��� Z
�f Hood—Fan _Other_ CITY Tel No. —
t �Ei TO APPLiCANT:If,after making this Certificate of pisp. _Room Air Cond._ LICENSE OR ♦ l_
rr ption, you should become subject to the Warkers' � - REG.NUM6ER�K� Class ��
P �ensation provisions of the Lebor Code,you must forth• power Apparatus&Large Appliances DIS7RICT NO. PHOCESSEO av
comply with such provisions or ihis �ermit shetl be Size&Type HP,KW,KVA,or KVAR � �\\/�\
�ed revoked. � Up to 1 Inel. � � O ' ' ` �� .
FINAL '
Over 1 to 10 Incl. DA7E VALIDATION
LICENSED CONTRACTORS DECLARATION Over 70 to 50 Incl. y_�� �2
�trehy aftirm that I am licensed under provisions of Chaptet Ove�50 t0 100 InC, aY A� .
commencing with Section 7000)of Division 3 ot the Ausi- Over 100 ` '
.s and Protessinns Codr,and my Iicense is in full force and � � ��
'ect. � / . Services �. "
.cense Number �'�✓YLic.Class "'�� + . 0-200 Amp.Under 600 V � . . �
��� �,f�/} �!— 201•1000 Amp.Under 600 V
'ontr r L �..5 d 44�I"i'?S� Over 1000 Amp.or Over 600 V
IfObfE 01VNER•BUILDER�ECLARATION Temp.Power Pole&Appurtenances � � \ � � - �
1 here6y affirm that I am exempt from the Contractor's Sie�n with One Branch Circuit . �� �
License Law for Ihe followinR reason(Section 7031.5,Auci• Additional Sign Branch Circuits,
ness and lMofessions Code): . � - � � i0
Misa Conduits&Conductors (� T5
� I, as owner of the property,will do the work end the Other(See Complete Fee Schedule)— . v`���1�
siructure is nat intended nr ofkmd for sale (Section
7044,Business and Professions Code). � . ` 1`1 l�,C�,I
CONSTRUCTION LENDING AGGNCY � T'
�1 hereby aflirm that there is a consiruction lending zRency
for the perfmmance of the wnrk for��•hich �his permit is pERM�T FEE (Sub-Total) �
issued(Sec.3097,Civ.CJ. � � -
Lender's Name pLAN CHECKING FEE (One•Fourth Permit Fee) ' ' - �
LendePs Address pERMIT ISSUING FEE .
1 certify�hat 1 have read [his appllcation and state that the TOTAL FEE � . `O , ,
above informetton is correct.1 agree to comply with a�l Coimry , - .
ordinances and State laws regulating Electrical wiring, and� � • - , �
hereby authorize re0resentetives of this County to enter upon� - � .
th ve- ntion properly for inspection purposes. � �
SEE'RCVERSE POR EXPLANATORY LANGUACE
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