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HomeMy WebLinkAbout1806A WORKERS'COMPENSATION DECLARATION 78A663 +oie� qppLICATION FOR ELECTRICAL PERMIT � � I hereby affirm Ihat I hava a cer[ifieate of consent to self insure, CE-806G pr a CertiF'�cate of Workers'Compensaiion Insurance,or a certif'�ed COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Saea 3800.Ls6.CJ / ��/ PoIiCy NO.�_��LO/��CAmp3lly�ND/�S/�X-//7 V FOfl APPLICANT TO FILL IN .' -" ' JOB h+d, EACH NO. -FEE AD�aESS O �NT�/ZI�' D/L ❑ Certilied copy is hereby lurnished. �. New Residential Bldgs.8 Poois,�,,,.,�� LOCALITY / � Certified topy is filed wilh the ou�ty bui�ding inspection 1 8 2•Family,Sq.Ft..�/� � _ �' rtmen ��� Multi-family Sq.Ft. - NEAREST Residential Swimming Pools cao5s Sr. Date� Applican � Ov'7NER oR /I.--.. � . ' flRMNAME //G/V . CERTIFiCATE OF EXEMPTION FROM WORKERS' putlets:Rec—Light—Sw.— ��� " � � M^�� COMPENSATIONINSURANCE � � �� - � � ADORESS i�. (This sectlon need not be eompteted if Ihe vrork involved by the First 20 permit Is lor one hundred dollars(5100)or Iess.) Total No. Additional � CIT / �� Tel.No. 7 I certify that in the performance of the work for whiCh this permit PLaN CHECK� � is issued,I shall not employ arry.person in arry manner so as to a��AM . . betome sublect to the.Workers'Compmsation Laws. L'ghtirg Fixtures First 20 ADDRESS-- � — � - - � � � Total No. ���ional CITY - �-� � Tet.No. Date Appl'�cant - Fxed Apptiances Not Over 1 HP � NO'TICE TO APPLICANT: If, after making this-CerMicate of AE��A��/r�� (' Exemption,}rou should become su6ject to the Workers'Compensatbn Range_Heater_D.W. _ provisions of ihe Labor Code,you must forlhwith comply wilh such Oven_�'yer_W.M._ - - ADDRES �O. � �/�/ � .provisions or this permit shall be deemed rewked. , . Top —FAU _W.H._ .. .. --- � CITY - / � /�� Tel.No. � � LICENSED CONTRACTORS DECLARATION Hood_Fan _Other_ �I hereby affirm that I am licensed uMer provisions of Chapter 9 . Disp. —Room Air Cond. _ uCENSE oR A-�� Ga��O �(eommencirg with Section 7000)of DHision 3 01 the Business aM AEG.NuuieER (/C� Pf0f2SSi0n3 COdB,end fny IiCBnS@ IS ir1(UII(OfCB dild B(}2Ct. , DISTRICT NO. PROCESSED BY � Power Apparatus&Large ApplianCeS ,/y� Size 8 Type HP,KW,KVA,or KVAR , O \`�0.\�V\� � O License Number_�Lic.Class C�O - �lJp to 1 tritl. . . . FINAL �'7� . ... U l� _�� Over 1 to 10 Incl. DATE / / ' 9 VALIDATION � �'��Z�-�NT�+ Datc � � � i �Contrac[or Over 10 to 50 IncL � FlNAL � ❑ I am exempt under Sea , Over 50 to 700 Inc. BY_ . W � 8.&P.G for this reason Over 100 N' � Services,Swbd.,MCC 8 Panei6oards� � � � `� �Q Q 6-� Z -� - -Date: 0-200 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V - � �� -�� �� �• • s w e 2 Over 1000 Amp.ar Over 600 V � � Exemption for Reg.Maint.Elect. - � - � .. � • � 2.�.(j�j . [ . .-... . . .�.-. .- S!NGLE FAM!LY ....-.... . � . Tem?.�r Pole&Appurten2nces . .. . . . e e � 2�,���� I HOME OWNER-BUILOER DECLARATION Si9n with One Branch Circuit I heiehy affirm[hat I am exempt fmm the Con[ractor's License Law Additional Sign Branch Circuits Q 9,2�—fj a for the foltowing reason(Sedion 7031.5,Business and Professions Coae): ❑ 1,as owner of fhe ro r wiil do the work and the shucture Misc.Conduils 8 Corductors - �- � - -� - - �. � p �ty' Other(See Complete Fee Scheduie is not inteMed or offered for sale(Section 7044,Business �— ► . .. . . ___.. .. . . . , an m essons e. -- � -- - - - � � - - - � � CONSTRUCTION LENDING AGENCY - - - � - � � � - � - . - . .. I hereby affirm that fhere is a eonstn�etion lending ageney for the � performance of the work for which ihis permit is issued(Sec.3097, . pERMIT FEE-� - �- ��--� - - - - (Sub-7ofal) .//v . _ Civ.C.l. _.__._... . .._.. ._ PLAN CHECKING FEE _ .. .. . . ... . LerMer's Name PERMfT ISSUINCa FEE, . . Q Lender's Address I certity that I have read this application and state that the abwe TOTAL FEE ��� � � infwmafron is correct.I agiee to compy with all County ordinances � � �- - � - � � � � and State lavrs regulating Eledrical wiring,and hereby aulMrize � representatives of this County to enter upon the above-mentioned�� �. - � � �'� � � - - �- ��� � � ' �� � � � - -� - - --- -� or inspeetan purposes. ��� n/�/� . SEE REVERSE FOR E%PLANATORY LANGUAGE. . . . .. .. . . . . Signature of Permittee 7 Date . . � ��.��i.,..-��r ,. •_--- � E - ' � � . , � ! � f I , � , ! . 1 , � � . . ; • : . ` � • . _ �. `i: �� � . 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