HomeMy WebLinkAbout1630A (17) WORKENS'COMYENSA7IONDECLARATION 76A663 APPLICATION FOR ElECTRICAC PERMIT � �
CE-806G 12$0) -
I hereby affirm that [ have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,oc
a cenified copy[hereaf(Sec.3800,Lab.C.)
FOR APPLICANT TO FILL IN �pg � I�
� Policy No. Company EACH NO. FEE ADORESS �'L� � �j
New Residential Bidgs.&Pools
� Certified cnpy is herehy turnished. t&2-Family,Sq,Ft. $- — $ LOCALI7Y �lQ�
❑ Multi-family Sq.Ft. — A T
Certified copy is filed with the coun[y building inspection CRO5S ST '�JE1 5 C O !
department. Residential Swimming Pools FIqM NAME � G �
� Dnte Applicant Outlets:Rec.S�Light_Sw.� � MAlL �
First 20 AbDRESS
CERT[F[CATE OF EXEti1YTION FRUM WORKERS' Total No.� Additional CITY Tel No. �i�(�.—� '�
COMPL•'NSAT[ON lN5URANCE PIAN CHECK } �'�
APPLICANT �'
(This section need not be completed i[the work involved �O O �
by the permit is for one hundceci dollara (5100)or less.) Lighting Fixtures First 20 ao�aess V �
Total No. Additional
� � �
I certlfy that in thc performance of the work for which this GTY � Tel No. O I
Fixed Appliances Not O�er 1 HP �,
permit is issued,1 shall not employ any person in any manner PERMIT V
so as to become subject[o the Workers'Compensation Laws. Range_Heater_D.W. APPLICANT W
OV¢n _Dryef_W.M._ ADORE55 a
y
Uate Applicant � Top _FAU _W.H.._ Z
Haod—Fan _Other_ ClTY Fe�nia.
NOTICE TO APPLICANT:If,aFter making this Certificate of Disp. _Room Air Cond._ UCENSE 4R �
Exemption, you should becume subject to the Kbrkers' REG.NUnneER Ctass �
Compensation provisions of the Labur Cude,you m�st forth- powEr Apparatus&Large Appliances DISTRICT NO. PRO ED BY
with comply with such provisions or this permit shall be �
deemed revoked. �Size&Type HP,KW,KVA,or KVAR �
Up to 1 Incl.
FINAI �
Ov¢r 1 t0 1D Incl. DATE (,j r(�((.�/ VALI ,TION I
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl, f� �L �
I hereby affirm that I am licensed under provisions nf Chapter Over 50 to 100 Inc. FINa� �
9 (commencing with Section 9000)of Divisiun 3 of the Busi- B� r/y �
Over 100 ��
ness and Professions Code,and my license is in full force and
effect. Services �
License Number Lic.Class 0-2D0 Amp,lJnder fiOQ V
201-}000 Amp.Under 6U0 V
� Contractor Date Over 1000 Amp.or Over 600 V �
HOME OWNER-BUILDER DECLARA'f10N Temp.Power Pole&Appurtenances
t hereby ef£�rm that ] am exempt trom the Can[rac[or's Sign with Qne Branch Circuit .
License Law for the fullowing reuson (Section 703L5�, Busi- Additional Sign Breneh Circuits
ness and Rofessions Code):
�{{{ � Misc.Contluits&Conductors
I; as owner of the property,will do the work and the Other ISee Complete Fee Schedulel—
structure is not intended or offered for sale (Section �1 6 3:0 A i
9044,Business and Professions Code). ��p�jO � �
CONSI'RUCTION GI;NDING A(3F,NCY �� ��-�'��I,R a U
1 here6y nffirm [hat ihere is a mnstruction Iending agency a�96d
for the performance of the work for whieh this permit is PERMITFEE (Sub-Total� ��3'�� �223`82
issued(Sec.3097,Civ.CJ. � „/�,3(� -
LendePs Name PLAN CHECKING FEE lOne-Fourth Permit Fee) �y �
Lender's Address � PERMIT ISSUING FEE � �
I certify that I have read [his application and state that the T07A1 FEE � �
a6uve informatiort is correct.I agree to comply with all County � �
ordinances and State laws regulating Electricel wiring, and
hereby thorize representatives of thia C un[y[o enter upon
ihe a v-mentioned pr erty f r insDe an purposes. / SEE�REVERSL fOR EXPLANATORY LANG[TAGE �
'� • ���J'0 Y
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