HomeMy WebLinkAbout1754A (10) WORKERS'COMPENSATION DECLARATION 76A663 APPLtCATfON FOR ELECTRICAL PERMIT 'I
� CESO6G(2-80)
[ hereby affirm that 1 have a certi£icate ot consent to self COUN7Y OF LOS ANGELES BUILDING AND$AFETY U
insure,or a certiCicate of Workerb%�Compensation[nsurance,or �
x certiCed copy thereoP(Sec.3800,Lab.CJ
FOR APPLICANT TO FILL IN J06 �Q �
i Poticy No. Company New Residential Bldgs.&P ol5„ EACH NO. FEE ADORE55
� Certifizd copy is hereAy furnished. i&2•Famity,Sq.Ft.� $ —' � LOCA�t7v
a Certified copy is filed with the count 6uildin Multi-family$q.Ft. NEAR T
y g inspection Residential Swimmin POOIs CROSS ST �
department. 9 OWNER OR �
� FIFiM NAME
Date Applicant Outle[s'Rec._,Light_Sw._ MAIL
First 20 ADDRESS
CERTIF[CATE OF EXEMPT[ON FROM WORKERS' Total No. Addii'ronai CIFv Tei No.
�
COMP£NSATIONINSURANCE a �
PLAN CHECK . O
APPLICANT
(This section need not be compkted if the work invo(ved V
by tlie pennit is for one hundced dollus (SI00)or less.) LigMing Fixmres First 20 ADDRESS
� Total No. �ditional O
I certify that in the pertormance of[he work for which this F�xed Appliances Not Over 1 HP CITY Tel No. U
permit is issued,I shatl not omp(oy nny pe[son in any manner PERMIT W
so as to become au6ject to the Workers'Compensation Laws. Range_Heater_O.W. qppLICAN7 a
-�' / " � Oven _Dryer_W.M.� ADDRESS � C _ Z
Date Appl gpt . a� Top _FAU _W.H._ —
Hood_Fan _Other_ CITY C �N TeiNo. �
NOTICE TO APPLICANT:If,after making this Certi£tcate of Disp. _Room Air COnd,_ LICENS pR �1� j
Exemption, you should become subject to the Workers' REG.NUMBEF Class q
CompensaHon provisions of the Labor Code,you must forth- Powet Apparatug&Large Appliances DISTRICT NO. PROCESSED BV �
with comply with such provisions or this permit shall 6e
deemed revoked. Size&Type HP,KW,KVA,or KVA `O v�,. (� �
Up to 1 Inci. ���,QY
FINAL
Over t to 10 Incl. �/+TE ` a � �Ja VALIDATI�N
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. 1
FINAL
I hereby affirm that I am licensed under provisions of Chapter Over 5Q to 100 Inc. B� 1
9 (commencing with Section 7000)oP Divisian 3 of the Busi- Over 700 j�-�--• �
ness and Professiong Code,and my license is in Cull force and '
effect. Services j
0•200 Amp.Under 600 V I
License Number Lic.Class Zp7�ipp0 Amp.Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V j
I
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �
I hereby affirm that 1 am exemQt trom the Cuntractor's Sign with One 8rench Circuit ;
License_Law foc the following reason (Section 7031.5,Busi- Additional Sign Branch Circuits
ness and ProFessions(:ode):
Misc.Conduits&Conductors ���
� 1, as owner of the property.will do the work and the pt er�$ee mplete Fee Schedule)_ � �
structure is not intended or offered for sale (Section I
7044,Business and Professians Code). "�
WNSTRUCTION LENDING AGF.NCY , j
�1 hereby affirm tha[ there is a cunstruction lending agency f
. for the perfurmance of the wotk for which thia permit ia pERMIT FEE � (5ub-Tntaq
', issued(Sec.3097,Civ.CJ. a�. �� ,���� '
` Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Fee) �
Lender's Address pERM1T ISSUING FEE _ ff� � � ���2 I
I certify that I have read this application and state that the TOTAL FEE f� � •G 4 i�U�
abuve information is correct.I agree to complY�+'ith all County
ordinances and State laws regulating Electricel wiring, and � '�4 ��v��'u
hereHy authorize representatives of ihis County to enter upon ry�_.. �
the ab ve-mentioned property for inspection purposes. SEE�REVERSE FOR ERPLANATORY I,ANGUAGF: � �,c�•�•." `
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