HomeMy WebLinkAbout1788A (10) WORKERS'COMPENSATION�ECLARATION 76A863 �o�e� ,qppLICATION FOR ELECTRICAL PERMIT��
I hereby affirm that I have a certificate oi consent to selt ins�re, CE-806c �
or a certiticate of Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFET�f--
copy iheie (Sec.3800.Lab.CJ
Po�icy No. %6�3 Comparry IN�U�'/�� FOH APPLICANT TO flLL IN �B
DDRESS � ��
� /N� EAGH NO. EE -
.Certified copy is hereby turnished. New Residential Bidqs.8 Pao � _ S LOCALfTY�� � �
'�=1 Cer if'ied'copy is filed with t aunty buiidirg inspection 1&2-Family,Sq.FL _
'�C 2fffI1Py MUlti-}dmily Sq.F�. NEAREST
(�.{/'/ CROS$ST.
Date o� ' Appiica Residentiai Swimming Pools - owNER oR
. . . . FttiM NAME
� CERTIFICATE OF EXEMPTION FROM WORKERS':� putlets:Rec_Light—Sw.�— � ��� �
� COMPENSATION INSURANCE - � � � aooaESS .�. �
(This seetlon need not be completed if the work involved by the ���20 �� a, 7 95
permit Is for ona huntlred Ao�lars(5100)or less.) . Total No. Additional -_ ��T Tel.No.
I tertify that in the pertormance ol the vrork for which this permit � . pp�i�N7 H- �
is issued,I shall not empbY�Y Person in am/manner so as to _
6ecome subject to tha Workers'Compensation Laws. - L'ghting Fixtures Frst 20 ADORESS
�� . ' . Total No. Additional ��y Tel.No. �
� �ate Applicant Fxed Appliances Not Over 1 HP peaMir /� i ��i�' �
,,T'"� E TO APPLICANT: If, after makirg this Cedificate of APRICANT C G�/wG �
. r�Fron,you should become subject to the Workers'Compensafron Range_Heater_D.W. _
. provisions o1 the Labor Cotle,you mus[forthwith comply with such Oven_Oryer_W.M._ ADDRE � � .
provisions or this permit shali be deemed rewked. � . _ __Top__FAU _W.H._ - � CITY ��,9 �� Tel.N���
LICENSED CON'fR4CTORS DECIARATION .� Hootl_ Fan _Other_ � '
� I hereby affirm that I am licensed under provisions o1 Chapter 9 . Dis —Room Air Cond. _ uceNse oR � . _ Cia��
(GOmmenciry wi[h Section 7000�01 Division 3 of the Business and p� REG.NUNBER
Protessions Code,and my license is in full force arid eifect. � Power Apparatus&Large Appliances DISTRICT NO. PROCESSEO BY �
License Number v V� Lic.Class` �� _ Size 8 Type HP,KW,KUA,or KVAR l.J �\O �
- �Up to 1 hicl.� � FlNAL - V
Contractor�=���`f� `-� Date -�� . �r 1 to 10lncl. �A� �—(''. VAUDATION _ 0
� Over 10 to 50 Incl. flNAL �j
❑ I am exempt urider Sec. _ Over 50 to 100 Inc. BV .
B.BP.C.for ihis reason Over 100 �'
- Services,Swbd.,MCC 8 Panelboards - �� � � � Z
...- ..- . . . Date:
0-200 Amp.Under 600 V
st9nat�re 20�-�o0o Amp.u�ae�soo v - �1 7 8.8 A
� �- � -� � - �---�- � � Over 1000 Amp.or Over 600 V �
Ezemptbn for Reg.Malnt Elect. �- - � �° � � � ��
� ��� � SINGLE FAMILY - � Temp.Power Pole&Appurtenances � o b 9 Q,j[G
l� HOME OWNER-BUILDER DECLARATION � Sign with One Branch Circuit
' �y aflirm ihat I am ezempt from the Contrector's License Law p�itional Sgn Branch Circuits ' ' ' '�/�� `���-�
h,._�Se following reason(Section 7031.5,Busirress and Rofessions � � - - - �
Code): �G.2 2—8 a
❑ I,as owner of tha Oroperry,will tlo the work and the structure Misa Conduits&Corductors-- - - � � - , ,
is not intended or olfered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ ,
ana Protessions Code).
CONSTAUCTION LENDING AGENCY � � � � �
I hereby affirm that there is a construcfion IeMing agency for the -
performanee of the work for whlch lhis permit is issued(Sec.3097, pERMR FEE -- � (Sub-Total) - - � - �� � � - � � �
Civ.Q�.
. PLAN CHECKING FEE ... . . - . - .
LeMer's Name /j�
PERMIT ISSUING FEE U
Lender's Address Q ��
I certify that I hava read this aDDlication and state that tha a6ove 7YlTAL FEE / _ � �
information is corred.I agree to comply with alt County ordinances
and Stata laws regulatirg Electr�al wiring,and hereby authonze �
representatives of this County to enter upon the above-mentioned �� -- - - - - - � �
prope lor inspection purpose� ��� SEE REVERSE FOR EXPLANATORY LANGUAGE . . . . __ _ . . _. �
��
Signature of Permittee Date
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