HomeMy WebLinkAbout1796A (19) WORKERS'COMPENSATION�ECLARATION 76A663 �o�e, qppLICATION FOR ELECTRICAL PERMIT� �
� CE-806G
I hereby affirm that I have a cer}iFica[e of consent to 9elf insure,
or a cer:pifinc'at,eG�of Workers'Compensation Insurance,or a certiFied COUNTY OF LOS ANGELES BUILDING AND SAFET��'��
PopCyhNd����y/NOvJ/«-J/J� FOR APVLICANT TO FlLL IN JOB
❑ Certified copy is hereby furnished. �N� New Residential Bldgs.&Poo CH ND. FEE
�Essa�3o3 �,. /an
� Certified copy is filed with the county 6uilding inspection
1 8 2-Family,Sp.Ft.� $ — $ LOCALIT � ��- /
NEAREST
Im�1en Mutti-family Sq.Ft. CROSS ST.
oate �v Applica � � R¢sidential Swimming Pools OWNER OR
FIFM Nl1ME O
CEATIFtCATE OF EXEMPTION FROM WORKERS' putlets Rec—L'ght—Sw.— ��� �T��
CAMPENSATIONINSl1FWNCE. " . ' ADDRESS •�. � r."�aC
(This section naed nct be compleled if fhe work involved by the First 20
permit is for one hundred dollars($100)or less.) To[al No. Additional CIT � � Tel.No. �7
I certify that in the performartce of the work for which this permit PLAN CNECK
is issuea,I shal4 rat employ any person in any manner so as to
nraucrwr
hecome subjecl h'�the Wakers'Compensation taws. �� L'ghting Fixtures first 20 A�DRESS
Total No. ���p��
CITY Tel.No.
Date -�- ���� Fixed ADPliarices Not Over 1 HP
NOTICE TO APPLICANT: N, aiter making this Certifica[e ot PERM�T �/� ���G
Exemption,you sF�ld becorne subjec}to the Workers'Compensation Rsnge_ Heater_ D.W. _ nPPUCANT
pmvisions of the�Labor Code,you musf�forthwith comply-with wch Oven_ Dryer_ W.M._ A�DRE55 x //��
provisions o uCENSED CANTRAGTO S OECLA ATION Hood— Fan _ Other_ CITY ��/�/(� ���I.No.J�' �
I hereby affirm that I am licensetl under provisions ot C�apter 9 uCENse oa � /
�isp. — Roan Air Cond. _ REG.NUMeER
(canmencing with Section 7000)ot Division 3 ot the 8usiness and / �
Professions Code,aM my ticense is in full face antl effect. DI37RiCT NO. PqOGESSE�av
Power Apparatus&Lar9e Appliances Q '
Q�,�� /� Size&Type HP,KW,KVA,or KVAR �Q �O��j�,p�
License Numher=�2{LY f6..L—Lic.Class` � UP to 7 Incl. FINAL Ll
Over t to t0lncl. DATE /Z��� VALIDATION �
C�ntracto��Tl�/�./� Date Over t0 to 50�nc�. e�� �Z o
❑ I am exempt under Sec. Over 50 to 100 Inc. �{y��
B$P.C.for this reason Over 100 Q,�
Services,Swbd.,MCC&Parrelboards � ^
Date: 0-200 Amp.Under 600 V - �
Signature 207-1000 Amp.U'xier 600 V
❑ Over 7000 Amp.or Over 600 V __
Ezemption for Reg.Maint Elect. -= � �%��--n
SINGLE FAMILY 7emp.Power Pole&Appurtenances �• • .s e - ,_,_
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's Liceose Law � � � � � �
tor the tdbwing reason(Section 7037.5,Business and Professions Additional Sign 8ranch Circuits `-��
Code�: • a j � , , .
❑ 1,as owner of the property,will tlo the work and the structure Misc.Gonduits&Gonduciors , ,
is not intended or offered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ � ��'.G G-c. :..
and Professions Code�.
CONSTRUCTtON LENDMG AGENCY - -_ -_�
I hereby affirm that there is a consfruCtion lending agency for the
performance ot the work tor which this permit is�sued(Sec.3087, pERMIT FEE (Su6-Total)
Civ.CJ.
PLAN CHECKING FEE
Ler�er's Name
PERMIT ISSUING FEE /(�
Lender's Atltlress /
I certify that I have reatl this application and state that the above TOTAL FEE
infortnation is correct.I agree lu comply wilh all County ortlinances
antl State laws regulaNrg Elect�ical winng, and hereby au[horize
representativea of ihia County to eMer upon the above-mentioned
proya y for insp��� ----.C� J .� SEE REVERSE FOR EXPLANATORY LANGUAGE
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