HomeMy WebLinkAbout1727A (19) WORKERS'COMPENSATION OECLARATION �6A� ,o.e� qpp��CATION FOR ELECTRICAL PERMIT � .
I hereby a((irm that 1 have a certificate of consent lo self CE�806G
i�su�e,o�a ce�rifica�e of workers'Compensation Insurance, COUNTY OF LOS ANGElES BUILDING AND$AFETY
a�Eeniii d copy th eof nrSec.38 Lab.C.)
��y ryO��–���C�'mpa 3 FOR Ar►LICANT TO fILL IN JOB 2 '
ADDRE55 �,J
Cerfified copy is hereby furnished. New Residentiol Bidgs.8 Pools EACH NO. FEE �
� Certified mpy is filed wilh the coun y building inspe �8 2-Fomily,Sq.FL 5 = E LOCALIT I
�ion epartment. Y Mulli-family Sq.Ff. NEAREST
♦/_. GRO55 ST.
Residential5wimmin Pools
�a�e r Applimnt • U�– 9 RMNA uU('
CERT fICATE OF EXEMPT N FROM WORKERS' Oullels:Rec_Light_Sw._ �j1°���
- COMPENSATION INSURANCE First 20 ADDRE55 . �
(7hi�s�ction navd nof 6e complH�d if th�work invo�vod hy Ta�a�No Addilionol CITY �Q ��C` Tel.No.� �
the permit t�for ons hu�dr�d dollars(SI00)or Is�s.)
I cerlify Ihat in�he performance of the work far which this . CHECK
APPLI
permi�is issued,I Sholl nol employ any person in any manner
so os to become subject�o ihe Workers'Compenso�ion Laws. Lighiing Fiatures First 20 AODRESS
Toial No. Additional
CIT e,
Date Applimnt � Fixed Applionces Nol Over 1 HP
NOTICE TO AP7LICANT: If, a(ler making this Certiiicate of PERMi�
Exemption, yoo should become sobject to the Workers' Ronge_Heater_D.W.— APPUCJrM '(' �
Compensolion provisionz of the Labor Code,you�musl forth- Oven _Oryer _W,M.— � ADDRE55
with comply with s�ch provisions or this pe�mif sholl be Top _FAU _W.H.— . �+
deemed revoked. � Hoad _Fan _Oiher_ CITY ' iel.Nor' _ �
. LICENSED CONTRACTORS DECLARATION � �I�EN$E OR �SIO� C1OS�+l
I herebyaifirm that I om licensed under provisions of Chapter9� Dis _Room Air Cond. — aEG.n7U+nBER
([ommencing with Section 7000)of Divis�on 3 of fhe Business power Apporofus 8 Lorge Appiiantes DISTRICT NO. PROCESSEO BY
and Professians Code,and my license is in full{orce ond efiecl. /d !�
Size 8 Typa HP,KW,KVA,or KVAR � �
License Number Lia Class Up to 1 IncL FINAL - . . V
3�O�er 1 to 101nc1. DATE ypUDATION �
Conrract � Doie_�� Over 10 ro 50 Ind. � � •
� FINAL V
I o exempt under Sec. Over 50 fo 100 Inc. BY �,y
B.BP.C.for this reason Over 100 - y
� Dote:� � Services,Swbd.,MCC 8 Panelboards , . ?
0-200 Amp.Under 600 V
Sgnature 401-1000 Amp.Under 500 V .
� Over 7000 Amp.or Over 60p V ?� 7 2']A .
Exemption for Reg.Moint.Elec1.
�}�•a o a o Z
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �
HOME OWNER-BUIIDER�ECLARATION Sign with One Bronch Cirtuil – � • •� ]Jr Q
I hereby affirm ihat I om eaempt from the Controtfor'S License qddi7ionol Si n&onch Circuih �
Low for�he following reason(Sec��on 7031.5,8usiness and 9 � • a • � '],�-�i(1 T
Professions Code): -
- � Mrsc.Conduirs&Conductors ►/ � � � �( �7 2 9"8 5 �
I,as owner of the properly,will do ihe work ond the ,
struclure is not intended or ofFered for sale(Section Other(See Compleie Fee Schedule)_ �I� y
70d4,Business and Professions Codej. / � -
CONSTRUCTION LENDING AGENCY . -\ ,
I hereby a(tirm thot lhere is a mnstrutlion lending agenty for �� ,
the performante of the work for which this permit is issued PERMIT FEE � (Su6-Total) � �
(Sec.3097,�;�.�.,. � rr.-:
PLAN CHECKING FEE `/,
� Lender's Name � �
. PERMIT ISSUING FEE _ jJ �[ �.,
lender's Address
I certify thot I have read ihis opplication ond stale Ihol fhe TOTAL FEE / � - '
abave information is correU.I agree lo mmply with oll County - �
ordinances and State laws regulaiing Elecirical wiring,ond
hereby a horiz epresenlotives o ihis County lo enler opon
obo -men oned p r for spection rpos s./ SEE REVERSE FOR EXPLANATORY LANGUAGE
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