HomeMy WebLinkAbout1773A (10) WORKERS'COMPENSATIONDECLARATION 78A663 +oiB+ qppLICATION FOR ELECTRICAL PERMIT �z . �
I hereby atti�m lhat I have a certifcate of consent to self insure,
CE-BO6G
or a certificate of Workers'Compensatron Insurance,or a certiFied COUNTY OF LOS ANGELES BUILDING AND SAFE
topy ther f� c.3800.Lab.C.) ���
Pol' N. � ���0�/"'/�
iCy Cpfjlp� FOR APPLICANT TO fllL IN - J09 .:v�d
❑ CertiFied copy is hereby furnished. �� . New ResidenC�al Bldgs.8 Pool EACH NO.. EE._ ��ESS 8 /V/c.fc�/7 �
� Certif'�filed with the county Wilding inspection 7&2•Family,Sq.FL� � — � LOCALIT �. �� �,
� rt en Multi-family Sq.Ft. — NenReST .
/yy� CROSS ST.
Date � Applican ��/r Residentiai Swimming Pools OWNER OR
- � . FIRM NAM N �
�� . CERTIFICATE OF EXEMPTION FROM WORKERS� - \ � MAI� �. ? �
Outlets Rec_L'ght_gw,— J
� .COMPENSATIONINSURANCE � -� aooaeS
(This seCtlon naed not 6e compleled I(the work imolved by the Frst 20
permit ie for one hundred dollars($100)or tass.) . Total No. Addilional CI N �70� Tel.No. 67
I certify that in the pertormance ot the work�for which this permit _ Pt-nr�cneCK �
is issued,I shall not empioy arry per5on in ary manner 5o as to A�tCAM
become subiect to the Workers'Compensation Laws. _, , L'ghtirg FixWres Frst 20 AODRESS � —
' - . Total No. A�iiionat CfTY � � Tel.N0.
Date � •Applicant Fxed Appliances Nol Over 1 HP PERMIT i +
NOTICE-TO APPLICANT: If,.after makinq this Cerlificate of AP��AM (` Q G
Exemption,you shoultl 6ecome sublect to the Workers'Compensation Range_Heater_ D.W. ,
.pmvisions of,the La6or Code,you must forthwith compiy with such Oven_ �ryer_ W.M._ ADDRESS ,� � -�/�� - �
,provisions or this permit shall be deemed 2voked. ' Top _—FAU _ W.H._ _ _. - - � - CITY �^/v 9i7��Tel.No59�j
LICENSED CONTRACTORS DECLARATION� Hood_Fan _ Olher_ .
I.here6y,af(irm that I am licensed under provisions of Chapter 9 .Disp. —Room Air Corid.._ LIGENSE OR ��az �
(commencirg wifh Sectian 7000)of Oivision 3 of the Business and REG.NUMBER
ProfOSsions Code,end my licens0 is in 1u11 force and ef(ect. aSTRICT NO. PROCESSED BY �
Power Apparetus 8 Large Appliances /`' �/1/�
���j��-� Size&Type HP,KW,KVA,or KVAR �v \�\ � 011 O
� Lieense Number���Lic.C�ass � - UP to 1 IncL �� FINAL q JQ 9 . . .. U
r�.��y��.�/ Over 7 to 10 Incl. �A�/4�Q/ VALIDArON �
Contractor ���L1�L(�fl 1..� Date Over 10 to 50 Incl. U
❑ I am exempt under Sec. Over 50[0 100 Inc. FINAL �
. . 6.8P.Q(or this reason Over 100 . BY �,` .. . . � ,
Services,Swhd.,MCC 8 Panelboards � �� � � - _ Z
� � - �ate: - 0-200 Amp.Under 600 V
Signature �- � -201-1000 Amp.Under 600 V -�� � -- � � � � � � �
❑-� - � � �� �� - � � �� Over 1000 Amp.or Over 800 V ?� 7�,J� .
Exemption for Reg.Maint.Elect. , . ,
-� - �� �SINGLE FAMILY� �-� - Temp.Pov+er Po�e d Appurtenances �• e s • s'L
HOME ONRJER-BUILDER DECLAflATION Sign with One Branch Circuit - � � � � � � �'�(a a 2
I hereby aflirm that I am exempt from the Contractor's L�ense Law a����al Sgn Branch Circuits
for the following reason(Sec[ion 7031.5,Business and Rntessions � �
coae�: • • +7 6�s 2�
❑ I,as owner of the pmperty,will do the xrork and the structure � Misa Conduits 8 Conductors - - - - � �9 2 2-�B
Is not intended or ottered tor saie(SecYan 7044,Business Other(See Complete Fee Schedule)_ , -
arM ProFessions Code). � � � � �-
CONSTRUCTION LENDING AGENCY �� � -- � . . . _._ ,
I hereby atfirm that there is a construdion lendirg agency tor the �
per(ormance of fhe work for which this permit is issued(Sec.3097,_.. .pERMR FEE� �--- � -�� ��� (Sub-To[al) ..
Civ.C.). � �� . . .
. PLAN CHECKING FEE . _ . _ . _
Lender's Name O
� PERMR ISSUING FEE
Lender's Address - �
I certify that I have read this appiication and state ihat tFu3 above . TOTAL FEE �� �
information is correct I agree to comply with a�l County ordinances . -- - - � . � - -
and State laws regulating Elettrieal wiring,and hereby authorize .
representatives of this County to enter upan the above-mentioned--� - � �"- � --" -- -� � - - -
� proper (or inspec[ion purposes. � � SEE REVERSE FOR E7CPLANATORY LANGUAGE . _ _ . _ "
/I"�r 2.� ��S
Signa[u2 of Permittea Oa[e .
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