HomeMy WebLinkAbout1800A . WORKERS'COMPENSATION DECLAR4TION �- 7sA663 ,o,e, qppLICATION FOR E�ECTRICAL PERMIT ''� �
i hereby affirm that I have a certificate of consent to self insure, Ce-eoac J7
a a certificate of Nkrkels'Canpensation Insurance,or a cer[ified I I
copy there c.3800,Lab.G) '
COUNTY OF LOS ANGELES BUILDING AND SAFETY � ��
PollCy Na�B� (�pmPy�y/N�v � FOfi APPLICAPIT TO FILL IN .108 C
❑ Certif�d coPY is herehY tumished. � ' New Residential Bldgs.&�s��S,� �H NO. �E ADDRESS J i .
� 1&2-family,Sq.Ft.�� $ — $ LOCA�{TV L�� �
Certifietl copy is filed with Mre ounty building inspection
[men MUlti-family Sq.FL CHo9SE S7.
�ate � � Applican[ � Residential Swimming Pools pWNER OR
FIRM NAME
CERTIFtCATE OF EXEMPTION FROM WOF#(ERS Outlets Rec—Light_Sw.�
CAMPENSATION INSURANGE - qp�Ec„5 �� 3
(Thia sactiw��ed not be compieted.ft the wwk invdved by the First 20
permit is for one hurxlred dollars(5100)or less.) Total No. Additional ��T Uj�C,/a�, 9�j�J�3. 7e1. ��f/
1 cartrfy that in the Rartwmance ot the work for which this permit PLAN CMECK
is iss�d,I shall not empby arry person in arry man�r so as to
APPLICANi
hecome su6ject to the Workers'Compensation Laws. Lighting Fixtures First 20 AODRESS
To[al No. Additional
CITY Tel.No.
Date Applicant Fized Appliances Not Over 1 HP
� �E TO APPtJCANT: If, �afber making-this Certificate of — PERMfT /� ,�
�Wion.Ya+sF7ould become suhject to the Workars'Cqn�pensation ��—Heater_ �.W. APPlICANi L
provigipng ot ths I.abor Code,ypu mus(forthrrith comply with such Oven_ Dryer_ W.M._ AODRESS ,(�, x ����
provisions or this permit stWl he deemed revoked. ToP ---- FAW _ W.H._ /�� n J 7v „�{�� /
LICENSED CANTRACTORS DECLARAT�ON tiood— Fan _ Other_ C�T 7 TeL i.c��
f hereby affirm that I am licer�setl under provisions of Chapter 9 Disp. _ Room Air CorM. — uCen�se oa �i 2 ��G
(commen�Jng with Section 70001 of�ivision 3 of the Business antl raec.ntunneEa d�+ ���
PrWessions Cotle,antl my license is in fuil force and effect. Power Apparafus 8 Large Appliances DISTRICT NO. PROCESSEO BY
c�,c/�I/y./)� � Size 8 Type HP,KW,ICVA,or KVAR �
Lieense f�umber�G"'�lbZ Lic.Class C�v � � `O/` � �
Up to 1 Incl. FINAL U �
���� Date� Over i to 70 InCI. �ATE �3Q`V � VALIDATION �
�trac Over 10 to 50 Incl. a 0 f
I am exempt under Sec. Over 50 to 100 Inc. Qy�� (�,/ U
B.BP.C.for this reason Over 100 0 F� g r.,;;, d
N
Services,Swbd.,MCC&Panelboards � Z
Date: 0-200 Amp.Under 600 V � � � ` `' �-
Signature 207-1000 Amp.Untler 600 V
❑ Over 1000 Amp.or Over 600 V � ` I � ��'�O �
Exemption for Reg.Maint.Elect ,
c : ! I ; �, �
SINGLE FAMILY Temp.Power Pole&Appurtenances �
� HOME OWNER-BUIL�ER DECLARATION Sign wilh One 8ranch Circuit �'���G - �
i�y atfirm that 1 am exempt irom the Contractor's License Law
che tdbwing reason(Section 7037.5,Business arM Professions �'���Sign&anch Circuits
Codeh. �
❑ I,as owner of the property,will do the work and the structure Misa Conduits 8 Canductors �
is rwt irrtended or oNered fa sale(Section 7044,Business aher(See Complete Fee Schedule)_
and ProTessiuns Code). ►
CONSTi7UCTION LENDING AGENCY
I here6y atfirm that there is a construction lending agericy for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Q5 �
Civ.C.).
PLAN CHECKING FEE �
Lentler's Name
PEAMIT ISSUING FEE Q
Lender's Atldress �
I certify that I have read this appiication end atate that the above TOTAL FEE /
. informaiion i5 Cor2ct.1 apree to comply with all County ordinances
and State laws regulating Elec(rical wiring, and hereby authorize
represerrtatives of thig Counry to entei upon the above-mentioned ��
oper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �
��� /.Y��. ���'
Signature of Permittee Date i
4
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