HomeMy WebLinkAbout1225A (11) W'ONKERS'COMPENSqTIONDECLARATION 76n663 APPLICATtON FOR ELECTRICAL PERMIT �
� CES06G(2•80)
1 herebv afEirm that I have a certiPicate of consent to self COUNTY OF LOS ANGELES BUILDWG AND SAFETY
insure,or a certificate of Warkers'Compensation Insurance,or
�r�le���y�theF��(�ec.3800,Lab.C.) .
� j� ��� FOfi APPLICANT TO FILL IN JOB , i I i f�
�.� Olicy No. Company EACH NO. FEE AO�RESS �l7 tt !NG
- � � New Fiesidential Bldgsi&Pools
� Certified copy is hereby furnished. � 1&2-Famtly.5q.Ft. $ � $ LOCAUTY �� NQ ,�
�c]Y� Multi•family Sq.Ft. —' N n EST �r �
�CeFtiSed copY ie filed wiih the county building lnspedian CROSS ST 6.7
department. . Resi nti81 Swimming Pools �OWNER Oft
���' � ' J'D � FIflM NAME O S
Dqta � =7��?Applicant e'� Outle s:Rec.._Light_Sw.� qODRESS G/ � p
First 20 n r,�—�
CERTIFICATE OF EXEMPTION FRpM 4V'ORKERS' Towl No. Additional CITY��� �y Te� �—p�p..�c }a �
COMPENSATION INSURANCE . PLAN CHECK '-J •
APPLICANT W �
('�'his section neeQ not be completed if the woik involveel Llghting Fixtures First 20 ADDRESS �j�s i
b� the permit is fm one hundre dollaza(St00)or less.) qdditionaf `�� �
� Total Na- CITY — �R Tel s 07 V
l.certify tAat ' the performa e of the work for which this Fixed APplianceE Not Over t HP
parmit is issued, shat!not ploy any person in any manner PERMIT . W
so as to become 3ect t hc W'orkers'Compen5atinn Laws. Range_Heater_Q.W._ APPLICANT � N
Oven _Dryer_W.M._ A�DRESS 6a$ �d�^� _ �A Z
J ^�—� � Tap �FAII _W.H._
�� Date�Ap ica Hood._Pan _Other_ C17Y r��N . S _yd75 �
hOT10E TD AYP CANT:if,a r.making this CertlFicate of Disp. _Room Air Cond._ LICENSE OR �_� �
Exemption, yo should becom subject to the Workers' REG.NUMBER �o C1ass
Compensatiun rovisions of the Laboi Code,you muse forth- power Apparatus&Large Appliances DIS7PICT rv0. PROCES EO BY
� with comply with such pmvisions or thia permit shall be S'tze&Type HP,KW,KVA,or KVAR �a
deemed�evo nd. Up to 1 Ind. ���
F INAt
Over 1 ta 701nct. Da7E ,� .� VALIDATION -
L[CENSED CONTRACTORS pE:CLARATION Over 70 to 50 Incl. � �'�
Over 50 to 100 Inc. FINAI. ^
[hereby affirm[hat I am ficensed under provisions of Chapter BY �
9 (commencing with Sectiun 9000)of Division 3 of the Busi- Over 100 �, �
ness a�d Prnfessions Code,and my license is in fuli force and
effect. Services
�/��j�s �'�s� 0•Z00 Amp.Under 60Q V
, Lice��� 'Number_L_ Lic.Class yp�.ipp0 Amp.Under 600 V
Contractor F•��Cll1/�✓G Date ��'��2 Over 5000 Amp.or Over 600 V .
HOME OWNER-BUILDER D�CLARAi[ON Temp.Power Pole&Appurtenances .
1 here6y aff'vm that t am ezempt from the Contrac�or's S�9n with One Branch Circuit �
License Law fur the following reason (Sectiun 703L5, Husi- Additional Sign Branch Ckeuits
ness and Professions Code): ��� 2 2-5 A
Misc.Gonduits&Conducmrs
� � I, as owner of the property.will do the work and 1he Other iSee Complete Fee Schedute)— #��� � � �2 �
structure is not intended or offered for sale (Section ' � �.��Je Q [
7044,Business and Protessions Code). �
CONS7RUCTIUN LENDING AGENCY �
I hettby aFfirm thnt there is a cunslruction lending agen�Y � � ��F'S C�'
for the performance uf the work for which this permit �s pERMIT FEE ISub-Totall �Q Q
issued(Sec.3097,Civ.CJ� O�.O 7`a 2 �
Lender's.Name PLAN CHECKING FEE (One-Fourth Permit Peel �
Lender's Address PERMIT ISSUING FEE � f
�
I certify that 1 have read this application end stare[hat the TOTAL FEE
above information is correct.t ugree to comply with all County
ordinances and Sta[e laws reguleting EleCtricnl wiring, and �
hereby authorize reprcsentatives of this County to enter upon
the ebov-mentioned propertY far InsDection purposes. S�:E'REVERSE FOR EXPI,pNATORY LANGLIqGE
�'W��'-� � - �
"�� Date
Signature of Permittee
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