HomeMy WebLinkAbout1817AWORKERS'
haw a COMPENSATION DECLARATION 78-803 10,61 APPLICATION' FOR ELECTRICAL .PERMIT
I hereby affirm that 1 have a certificate of consent to self insure, CE -806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy there f c. 3600,Lab. O)
Policy No. Comparry FOR APPLICANT TO FILL IN - - - JOB
❑ Certified copy Is hereby, furnished. -...;- �, New Residential Bldgs. 8 EACH NO. - FEE - ADDRESS Iv Q/C-
- Certified copy Is filed with the my building inspection 1 & 2 -Family, Sq. Ft. �_L S —1s7 () LOCALIT � r -
n1. J Multi -family Sq. Ft. NEAREST
CROSS ST _
ER Oil
Date Applicant Residential Swimming Pools
FIRM NAME 4
CERTIFICATE OF EXEMPTION FROM WORKERS' - MAIL
-- : COMPENSATION INSURANCE, - • Mets: Rec— Light _ Sw. — _ ADDRESS
(This section need not be completed it the work involved by the First 20 7
permit Is for one hundred dollars ($100) or less.) - - Total No. Additional - - - - CIT �(/�. 9i7O� Tel. No. (//_Py
I certify that in the performance of the work for which this permit _. _ - . _. - PLAN CHECK - -
is issued, I shall not employ -arty person in any manner so. as to
_.- -Top -- FAU _-W.H.
- I - LICENSED CONTRACTORS DECLARATION -, ;
APPLICANT
become subject to the Workers' Compensation Laws.. , .
Lighting Fixtures
First 20._ -- -
ADDRESS - _-
-. r
Power Apparatus 8 Large Appliances -- - -- --
Additional
-'
(J�
License Number Lk. Class
Total No.
''-
CITY' -- --:- - Tel. No.
Date Applicant. _. .. .-.
ITICE'.TO--•APPLICANT:: If, after making this Certificate of
Fixed Appliances Not Over 1 HP
PERMIT 2
��''
,emption, you should become subject to the Workers' Compensation -..
-. Range— Heater_
_ D.W. _
- APPLICANT
>provisions of the Labor.. Code you must forthwith Comply. with such
Oven --_ Dryer _
W.M. _
ADDRESS a�/7 L�ittl ll//
provisions or this permit shall be deemed revoked..; ., I _.
_.- -Top -- FAU _-W.H.
- I - LICENSED CONTRACTORS DECLARATION -, ;
Hood _ Fan _ Other_
I hereby affirm thatl am licensed under provisions, of Chapter 9 - -
-Disp. _ Room Air Cond. ----- - -
(Commencing with, Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect
Power Apparatus 8 Large Appliances -- - -- --
,- S4
Size 8 Type HP, KW. KVA. or KVAR
(J�
License Number Lk. Class
_
Up to 1 Incl
y -
411
Over 1 to 10 Incl.
Contractor A� C-fL= Date
Over 10 to 50 Incl.
- ❑ .. I am exempt under Sec. - °-
- -- .Over 50 to -100 Inc....-
B.BP.C. for this reason
Over 100
-
- --
Services, Swbd., MCC B Parielboards- -
Date: -
0 - 200 Amp. Under 600 V
-
Signature_ - -
201 - 1000 Amp. Under 600 V-
"❑
Over 1000 Amp. or Over 600 V -
Exemption for Reg. Maint. Elect.
SINGLE FAMILY ��� �� _
Temp. Power Pole 8 Appurtenances
\ HOME OWNER -BUILDER DECLARATION
Sign with One Branch Circuit
-_ —by affirm that I am exempt from the Contractor's License Law
--tor the following reason (Section 7031.5, Business and Professions --
. Additional Sign Branch Circuits - - - -
Code):
❑ I, as owner the property, will do the work and the structure
Misc. Conduits -8 Conductors --" - - - -- - - -
d or offered for sale (Section 7044, Business __
' Is not intended
Other (See Complete Fee Schedulo
P - )--
and Professions Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, -
PERMIT FEE ' - (Sub -Total) - /0 f
Civ. C.). -
PLAN CHECKING FEE- - -
Lender's Name
PERMIT ISSUING FEE
' A
REG. NUMBER - umsk_
DISTRICT NO.
PROCESSED BY
0
FINAL
DATE
- - _ - - - V
VALIDATION.
-
_ .
_ ...
.
U
FINAL
ll
�181,7.a �
12 j.1
Lenders duress //
certify that I have read this application and state that the above . TOTAL FEE .. .. /,. 4/&
information Is correct. 1 agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned -
pQ!-
er :y7for �Inspection purposes.
�^,,
y�l(v/IV.SEE REVERSE FOR EXPLANATORY LANGUAGE..
Signature of Permittee Date -
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