HomeMy WebLinkAbout1808A WORKERS'COMPENSATIONDECLARATION )6A663 ,o,e, qppLICATION FOR ELECTRICAL PERMIT /� � �
I hereby aflirm that I have a certificate o1 eonsent to self insure, C6806G
or a certiticate Ut Workers'CompensaCan Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFET
copy 1here c.3900,La6.C.)
Poiicy No. Company�N�-ST��� FOR AP7LICANT TO FIIL IN .roe �q
❑ Certified copy is hereby furnished. ,.. . /NQ, New Residentlal Bldgs.&Po s - EACH NO. FEE AODnE55 �/l/��y� �,
� Certified�copy is filed vrith th county bui�dirg inspection 1 8 2-Family,Sq.Ft. 7 � � — S Q LOCALITY �'.� � � � �
ment Multi-femily Sq.Ft. NEAREST �f
CROSS ST. /,J
Date � Applica r ReSidential Swimming Poo�s OWNER OR ^�'
' � . F'117M NAM (�Y
. .' :�CEFiTIFlCATE OF EXEMPTION FROM WORKERS' . ' nnai� �?�
- � ,COMPENSATION INSt1RANCE Outlets:Rec—Light—Sw.— � ' p�oRESS .rY�C
(Thia sedion need not be completed if the work imolved by the Flrst 20
permit is for one hundred dollars(5100�or less.) Total No. Additional- CITV ��a Tel.No. ��
I certify that in the performance of the vrork tor which this permit . ttnN CNecK �
is issued,I shail rrot employ arry person in any manner so as to APP(.IC.4NT
- become subject to�he VJorkers'Compensation Laws. Lighting Fixtures First 20, ADDRESS - —
. Additional
�� Total No. CITV � � - Tei.No.
Date Appiicant Fixed Appliances No[Over 1 HP
N"-' E�TO APPLICANT: I1, after making ihis Certilicate ot PERMii / i� �' -L . �
.ti �tion,you should become subject to the Workers'Compensation Range_Heater D.W. _ AP����T
provisions of the Labor Cqde,you must forthwith comply with such Oveo_Dryer_ W.M._ AD�RESS ,� �f�f
provisions or this permit shall be deemed revoked. , Top _FAU _ W.H._ �
. LtCENSED CONTRACTORS DECLARATION Hood_Fan _ Other_ CITY���./� 9�7�fe1.N 9�p�
I hereby afti�m�hat I am licensed under pmvisions of Chapter 9 _Disp. —Room Air Cond, — uCENSEOR � ' C��/O
(commencirg with Section 7000)of Division 3 of the Business and REG.NUMBER
Rofessions Code,ard my Ilcense Is in full foroe and effeet DISiAICi NO. PROCESSED BY �
. Power Apparatus&Large Appliances �'y�
l}�� � /v/ Size 8 Type HP,KW,KVA,or KVAR � l'b.1 6�'� p
License Number � Lic.Ciass ��• - - Up to 7 Incl. FINAL �J �7 � �-� - U
-Contractor��Z��C�J�/ Date �� . Over 1 to 10 Incl. �A� 2 7'(j� VALIDATION 0
Over 10 to 50 Incl. FINAL �
❑ I am exempt under Sec. Over 50 ta 100 Inc. gy Q�/��
8.8P.C.for this reason Over 100 " N'
Services,Swbd.,MCC 8 Panelboarcls - - � - - Z
Date: 0-200 Amp.UMer 600 V . �� 8 Q A j1,
� Signature 201-1000 Amp.Under 600 V -
❑ - � - - - - �� - � Over 1000 Amp.or Over 600 V � $(• • e o 0 2
ExemD['ron for Reg.Maint.Elect.
� -- --SINGLE FAk!ILY � Temp.Power Pde&Appurtenances � • � C�'�4 b
HOME OWNER-BUILDER DECLARATION �Sign with One Brench Circuit - e • � 2��/!O�
I �by affirm that I am exempt 1rom the Contractor's Lieense Law Additional Sgn Branch Circuits
f,.�6 totlowing reason(Section 7037.5,Business and Professions � ' _ �9.G G—8� .
Codel: •
� � Misc.Conduits 8 Corductors . ,
I,as owner of the pmperty,will do the work and the structure p�her(See Complete Fee Schedule)_
IS no[Intended or Oflered}Of Sale(SeCtion 7044,6u5ineSS ,
an0 Professions Codel. -.. - . . . - . . .
CANSTRUCTION LENDING AGENCY -- - � - . .._
I hereby affirm that there is a constructton lentlirg agency for the � ' �
performance of the work for which this permit is iswed(Sec.3097, . .pERMfT FEE . (Subdotap �l(� .
C'rv.C.).
PLAN CHECKING FEE .. . _ ._. . . _ . _ . .
Lenders Name . �
PERMfT ISSU�NG FEE
Lenders Address • .
I certify thai i have read this applicafion and state that the abova TOTAL FEE a .
inform2tion is eorred.I agree to comply with all County oidinances � - - � � - �� .
aM Stata laws regulatirg Electrical wiring,and herehy autMrize
representatives of this Counry to eMer upon the above-mentioned - �
prop tor inspection purposes. SEE REVERSE FOR E%PLANATORY LANGUAGE
gnature of Permi tee Date - �
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