HomeMy WebLinkAbout1807A � WORKERS'COMPENSATION DECLARNTION ��6g3 �o�e� qppLICATION FQR ELECTRICAL PERMI��� {�
I here6y affirm that I have a cerlificste of conaent to self insure, cE-eoSG
a a certificate of Workers'Compensatbn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAF�� l,
copy tHe 3800.La6.C.)
PoIicY N.���pa�y�/YQ(/�/� FOH APPLICANT TO FlLL IN JOMDHESS a 3 .X—/�
❑ Certified copy is hereby furnished. ��� New Residential 81dgs.&Poo'• �7 EACH NO. FEE
� Certif� co y is filed with the ounty building inspection 1&2-Family,Sq.Ft. �7/ $ — $ LOCALIT 2 �" r
me Multi-family Sq.Ft. — NEAREST n
CRO55 ST. f�
Date Residential Swimming Pools N�
AppliC& OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' ` • � �� �,
, COMPENSATION INSURANCE Outlets:Rec_Light_Sw.� :.... � aooaess •O. � '�.
�Thia seetqn neod not be compieted iF the work Invdved by the First 20 ��,
permit Is ior.one hundred dollarc(S100)w less.) Total No. p�it� CIT � 9�� T�.�.9�,�p .
I certify that in the perfamance of the work fof which this permit PLAN CNECK -
is issued,I ehall rwt employ afry persa�in arry manner so as to ��� �
6ecort�subject ta the Workers Compensation l.aws. Lighting Fixtures First 2D ADDRESS �
Total No. ��iorval � �
Date Applicant CITY Tel.No. i
Fixed liances Not Over 7 HP
NOTICE TO APPLICANT: If, afffir mak'ug this Csrirficate of �P PERMiT �ji� ,�.�r ,
ExemWion.You sFnuld become subject to the Y�brkers Compensatiort Range_ Heater_ D.W. _ aeauGAM (/� ��'"JJ�/ i
provisia�s of ths l,abor Cotle,you rtwst forihw.itti comply_witt�such Oven_ �ryer_ W.M._ AD�RESS .� � ��� �
provisions or this permit stiall 6e deemed revoked. Top _ FAU _ W.H._ I
LICENSE�CONTRAC70RS DECLARATION Hood— Fan _ Other_ ��T � (� /�Q� 7e�.No. 9��r
I h9r0by affifm that I em Ncen3Bd URtlOf pfOVlslOns Of Ghap�el 9 p�0. _��a��� _ LICENSE OR D� _ /Y�_(;
(COmr�ncing Wifh Section 7000)of Division 3 oF The Business and REG.NUMBER Q �ssl�7V I
Profe53ions Code,ard my license is in full faCe and effect. qS7RICT NO. PROCE55E0 BY �
—�� � Power ApparaNs 8 Large Appliances O ��� �
,q� Size 8 Type HP,KW,KVA,or KVAR �
LicenSe Number v v Lic.Class � Up to i Incl. FFNAL '7�QG�
�������V Date---y�=� Over i to t0lncl. DATE /��./ (!/ VALI�ATION �
Gontract Over 10 to 50 1nc1. �
.❑ I am exempt under Sec. Over 5D fo 700 inc. BYAL W
B$P.C.for this reason Over 100 �
Services,Swbd.,MCC&Panelboards Z
Date: 0-200 Amp.Under 600 V � �_j R;;.'(;',
Signature 201-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V �� • s e + s%'�
� Exemption for Reg.Maird.Elecf.
SINGLE FAMILY Temp.Power Pole&Appurtenances � -� 'i ��,!; i
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � ;; —
1 here6y atfirm ihat 1 am exempt fmm the Contractor's License Law � �� '�- ���--
fa tbe tollowing reason(Section 7031.5,Business and Professions ��tional Si9n&anch Circuits
Code1: ��i,C C—....
❑ i,as owner of ihe property,will do the work and the structure Misa Contluits&Condudors �
is not intended or offered fa sale(Section 7044,Business Other(See Comple}e Fee Schedule)_
and Professbns Code). �
CONSTRUCTION LENDING AGENCY
1 hereby attirm that there is a construction lending ager�cy tor the
pertormance of fhe work for wtuch this permit is issued(Sec.3097, pERM1T FEE (Su6-Total} �f(� 6
Civ.C.�.
PLAN CHECKING FEE�
���s�� /D
PEAMII lSSU1NG FEE �
Lenders Addrass /�
I certify that I have read this application aM state that the above TOTAL FEE
infamatian is carrect.I agrea to cwnply wiM all County ordinancee
and State laws regulating Electricai wiring,and hereby authorize
representatives ot ttiiis CouMy to enter upon the above-mentioned
ta inspection purposes SEE REVERSE FOR E%PLANATORV LANGUAGE
�e. �'/�s�
ignature of Permittee Date �
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