HomeMy WebLinkAbout1783A (10) WOFKERS'COMPENSATIONDECLARATION CE-e06G '°'81 APPLICATION FOR ELECTRICAL PERMIT � JJJ'''III
I hereby aftirm that I have a certificata ot consent to self insure, `7 '
or a ceHificata of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY � �
copy thsre�(,�$ec�8�0 Lab.C.) �� L�
�
Policy No. ��o COmpZ QVS��� FOR APPLICANT TO FlLL IN ' JOB n'•
� A�DRESS (j7�
Certified eopy is hereby fumished. . , �N� New Residential Bldgs.8 Po�^� EACH NO. FEE �
I� 1&2-Fami�y,Sq.Ft. m v � S — � LOCALITY�/`/` a�'� �'
Certified copy is tited with the cwnty buiieing Inspection
4� ftm2[. - � �A Mulfi-f3fTily Sq.Ft. — NEAREST
(�/-�d� Residentiai Swimming Pools CROSS ST.
Date��O � Applican - ��✓��� � OwNEROR
� � � � � . ' , . FIRM NAME
. CERTIFlCATE OF EXEMPTION FROM WORKERS' p�tlets:Rec_L'ght_Sw.�— � Mai� X
.� COMPENSATION INSURANCE . . � .. . ADDRESS
.(Thls aeetbn need nol be eompleted if the work irnolved by the Flrst 20
..permit is tor one hundred dollars($100)or less.) Total No. Additional CITY �, Tel. . 67
I certify that in the performance of the work br whkh.this permit PLnN CnECK
, (s issued,I shall not empby any person in arry manner so as to AF'F'uCAM
— become sublect to the Workers'Compensation Laws. . . L'ghting Fixtures Fre[20 -- ADDRESS- � � —
.. � � . Additional �
' � . Total No. CITY � Tel.No.
Date Applicant Fized Appliances Not Over 1 HP
NOTICE TO APPLICANT:.If, after making this Certificate of PERMii / �
Exemption,you should becoma su6ject to the Nlorkers'Compensation_. Range_Heater_D W. _ ��CA�'�T
provisions of the Labor Cotle,you must brthwilh comp�y with such Oven_Dryer_ W.M. �_ - ADDRESS ,�_� � -
provisions o(ihis permit shall be deemed rewked. ,� _ Top_— FAU _W.H._ CITY /NJ ��7v� Tel.No.
LICENSED CONTRACTORS DECLARATION Hood_Fan _Other_
I hereby affirm�that I am licensed under provisions of Chapter 9 p L�CENSE OR ,q,�� ci�iy/O
(commexirg with Section 7000)of Division 3 of the Business and � Dis. —Room Air Cond. _ REG.tiunneER (/�/ Z..
Rofessions Code,and my license is in tull toroe and eFfect.�- oisrnicr No. raoCESSED ev �
Power Apparatus&La'ge Appliances ���,,,''''''1
License Number /l/�D_'S Lic.Class C�U Size 8 Type HP,KW,KVA,or KVAR � � � A �
Up to 1 InCI. FINAL n
�) ��,/ � Over 1 to 101nc1. DATE/��/X �.
Contracta f'�/�7��Gf7l-Date� � ' � p�r 10 to 50 Incl. - u� VALIDATION 0
❑ I am ezempt under Sec. Over 50 to t001nc. gyA�r��y//L 1'1� _ W
. . ... _ Over 700 '(/WC p,.
8&P,C.for ihis reason
Services,Swbd.,MCC&Parmlboards � �� � � - - - . - N
Date: z
0-200 Amp.Under 600 V
s�9nacu.e 2oi-�000 ama.w,de�soo v - z 1 7$�A
� --� - � � � � Over 7000 Amp.or Over 600 V
Exemption for Reg.Maint.Elett.
. �� • e s •�'�
�� � - - -� �� .-� SINGLE FAMILY �� - � � Temp.Povrer Pole&Apportenances
� HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ' � �- � • °9 G.3 4
I hereby a8irm that I am exempt from the Contradoi s License Law
Mr ihe followirg reason(Section 7031.5,Business arW Profeesions - Additional Sgn Branch Circuits _ _ . •.s c G(,�(;,�
Code): �
MiS�.co�a��ts s co�� 0 9•2 2-8 8
❑ I,as avner of the properry,wilt do the vrork and the structure �
� is not interded or offerea for sale(Sectbn 7044,Business Ofher(See Complete Fee Schedule)_ ►
and Professbns Code). �---- -- --- � - - - � -� -
CONSTRUCTION LENDING AGENCY - .- ---- -
I here6y affirm that there is a construction lending agency for the �
performance of the xrork for which this permit is issued(Sec.3097,_. .pERMIT FEE � � - � -� - - _ (Su6-Total) .
Civ.C.). � -� -
- ..... .PLAN CHECKING FEE. _.
Lender's Name //,
PERMR ISSUING FEE V
Lender's Address - � �
I certify that I have read this application and state that ihe above TOTAL FEE �,3
information is correet.I agree to comply with alt Counry wdinances � � - - � ��
and State laws regutating Electricat wiring,and hereby authorize
representatives of this County to enter upon the above-mentioned -' � -� -�- - --� --- - � �
prope for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�2����- �/��
Signature of Permitlee Date
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