HomeMy WebLinkAbout1815A Y WORKERS'COMPENSATIONDECLARATION 7�6.4_�G IOiei APPLICATlOfV �OR ELECTRICAL PERMIT � / I
I here6 offirm tFwi I hove a certificote of consent to self `/� /
insure,or o certcficote o!Workers'Compensai�on Insurance, COUNTY OF l05 ANGEIES BUILDIN�'s AND SAFETY �
or o certifigdf��,op�y/pth)e�re�o�f(Se�-3800.Lab.C.`) ,
P�olicy No��L�'QJ� Zompan N �J/��� iOR APPUGNT TO Fllt IN �pRE55 G� �j
Certified copy is hereby furnished. �N New Residential 81dqs.8 --y! EACH NO. FEE
� Ceriified copy is filed wilh the county building inspec- 1&2-Fomily,Sq.Ft.�/� � -- 3 LOCALIT � 37
y� depar ment. ���/// Multi-family Sq.Ft. NEAREST
L/� � �^nr Q��. CRO55 5T.
L /����l�L Residential Swimming Pools
Date Applicant� � OWNEROR /}
FIRM NAME N�v �
CERTlFICATE OF EXEMPTfON FROM WORKERS' Outlets:Rec_Light_Sw._ '�'�� �}
COMPENSATION INSURANCE ADDRE55 �. �,��7
(Thia aaNion naed not ba complofod iF fh�woric invalved by First 20 CIT �j Tel.No.p
1M p�rm{t Is for or hvndrod doflars(SI00)or le�s.� To�al No. Additionol v//��– // �a, /��
1 certify�hat in ihe performonce of ihe work for which ihis otANCHECK
permH is issued,I shnil not emptoy any person in any monner AFPtICANT
so as ta become xubject to fhe Workers'Compensotion laws. Lighting Fixtures First 20 ADDRESS
Total No. ���10�°�
CI1Y Tel.No.
Date /+ppliwN Fixed Appliances Noi Over I HP PERMiT i ro
NOTICE TO APPLICANT: if, aNer making this Certifiwte of A���T ���'�_('����x f�
� Exemption, you sho�ld become subjact to the Workeri Ronge_Heater..._D.W._
Compensolion provisions of ihe Lobor Code,you mus�forth- Oven _Oryer _W.M.— ADDRESS .�, y[ ����
with comply wi�h s�ch provisions or �his permit shall be Top —FAU —W.H.—
deemed revoked. CITY . � �(��'Tal.N . /��
LICENSED CONTRACTORS DECtARATiON Hood _Fan _Other_ �r
Disp. _Room Air Cond. — ���NSE OR Claaa.C,�� �
1 hereby dffirm 1Fio1 F om{icensed under provisions of Chaprer 9 REG.NUMBER
(mmmencing with$edion 7ppQ1 of Division 3 of the Businesa DISTRICT NO. PROCESSED BY 0-� �
Power Appamlus 8 large Appliances
ond Professions Coda,and my ticer*se is in full forca ond effed. (� ( ��
�y�' j Size S Type HF,KW,KVA,w KVAR 1,� �•\q,\�}/� � V �
LitenseNumbar Vv�^–� LiaCloss �v FINAL �
Up to 1 Irxl.
�,'���t�� � Over 1 to 10 Ind. DATE �_30.,QQ VALIDATION U
Conirocror Oote Over 10 to 50 Ind. �r
� F�NAI � W i
I am exempt under Sec. Over 50 to 100 Inc. BY �� �
8.8P.C.for this reasan O�er IOp z
Services,Swbd.,MCC 8 Panelboards �
Date: 0-2IX1 Amp.Under 8W V � -�1 `��L=.���� �
Signalure 201-1000 Amp.Under G0p V r• s e ,. . 3
❑ Over 1000 Amp.or Over 600 V �
Exemption for Reg.Maint.Elect.
SWGLE FAMIIV I � i [. i. e V �
Temp.Power Pole 8 Appurtenancee
� HOMF OWNER-BUIIDER DECIARATION Sign wilh One Branch Circuil � � i _ �;.L:c;�
I bere6y affirm thot 1 am exemp�firom the Controclor'c Licenu Additionol Sign Branch Circuils �
low for the following reoson(Section 7031.5, B�siness and n C��_>: �
Vrofessions Code): `
�
❑ I,as owner of the properly,will do the work and the Misc.Conduits 8 Canductors
strucWre is not intended or offered for sale(Section Other�See Complete Fee Schedule)_ �
7044,8usineu and Prafessions Code).
CONSTRUCTION LENDING AGENCY
1 hereby otfirm thoi there is a mnstruction lending agenty for
the performonce of the work fo�which fhis permit is issued PERMIT FEE (Sub-To�al) � 6 , �
(Sac.3097,Civ.C.).
PIAN CHECKING FEE
Lender's Nome PERMIT ISSUING FEE �O
lender's Address /� , `
I cerfify thar�have�ead ihis opplicotion and stote that the TOTAL FEE �
above informotion is correct.�agree to comply wi�h oll Coun�y
ordinances ond Stale laws�egulating Electrical wiring, ond
hereby autharize representotives of Ihis County to eNer upon
�S�"�ve-mentioned property for inspeUion ur ses.
�"'�� �/�/S SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa�ure of Permntee Dote� , �
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