HomeMy WebLinkAbout1281A (6) WORKERS'COMPENSATION DECLARATION 76A663 10/B) p,pp`tCATf�M FOR ElECTRiCAL PERMIT � I
1 hereby affirm thaf I have a cerlificate of consent to self CE-806G
insure,o�a certifica�e of Workers'Compensatio�Insurance, COUNTY QF LOS ANGELES BUILDING AND SAFETY
or a certified mpy thereof(Sec.3800,lab.C.)
P�olity No. Company fOR APPLICANT i0 Hll iN pDRE55'L �
Certified copy is hereby furnished. New Residentiol Bldgs.6 Pools �CH NO. FEE
� 1&2-famil Ft. f = f LOCALITY
Certified copy is filed with ihe county building inspec- Y��' r�� NEAREST
tion department. Mulli-family Sq.Ft. CROSS ST. �'L
a�
Residenlial Swimming Pools OWNER OR
Date AppiiCant FIRM NMAE
CERTIFICATE OF EXEMPTIOPt FROM WORKERS' Outfets:Rec�light_Sw.� '�'��
COM�ENSATION lNSURANCE AO�RE55
T[�i�aQeflen�ed noT 6s com {f IIN wwk Involved tt� First 20
f �d � Total No.� Additional CITY t� Tel.No.
tiw pNmif is ior aw kundred dolkra(5100}or loa.)
I cerlify Ihat in ihe performance of the work for which this PlAN CHKK
APRIGAM
permit is issued,I shall not employ any person in any maoner
so as to became su6ject to ihe Workers' ompe�sation Laws. Lighting fixNres First 20 A�DRE55 �i
r� To�ol No. �--0---' Add�tionaf
' ' qTY �� Tel.No. ��
Date ��App�icant Fixed Appliances Nol Over 1 HP pERhVT
NOiICE TO APPLI NT: If, ofter mokin t is Cehificate of AGVIICANT
Exemption, yo� shouid become subject to the Workers' Range_Heater_�.W._
Compensation provisions of the Lo6or Code,you must forth• Oven _Dryer _W.M._ ADDRE55 . if �
wrih camply with such prorisions or this permit shall be Top _FAU —W.H.-.-
deemed revoked. Hood _Fan _,.Other_ C�TY �� Tel.No. 1�
LICENSED CONTRACTORS DECLARATtON �' FICENSE OR
t hereby aH"am that 1 am licensed under pmvisions of Chapter 9 Disp. _Room Air Cond. _.�._ REG.NUMBER ��j� �- Class.
(commencing wilh Seclion 7000)of Divisian 3 of the 9usineu poN,er Apparatus 8 Large Appliances �ISTRICT NO. PROCESSED 8Y �
and Pro4essions Code,and my license is in full force and effect.
Size&Type HP,KW,KVA,or KVAR Q
License Num6er Lic.Class Up to 1 Incl. PINAI ' V R
Over I to 10 Incl. DAFE ��� �� yALIDATfON Q �
Contrado� �a� Over 10 to 50 Incl. F�Nq� . U
� I am exempt under Sec. Over 50 to 100 Inc. B� W
�
6.8P.C.for fhis reason Ovei 100 N
Services,Swbd..MCC&Panelbaards � z
Date: mp. n er _�7
Signature f-1000 A-- mp.�nder-600 V �
❑ Over 1000 Amp.ar Over 600 V
Exemption for Reg-MoinL Elect.
SINGLE FAMILV Temp.Power Pole 8 Appurtenances a �� 2 a� a
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuil ��
I here6y affirm fhat I am exemgt from the Commcmr's ticense ' �• • • • •2
AddFfioral Sign Branch Citcvits ��
Law for ffie following reason(Seciion 7031.5, Business and � ���a�C�
Prof ssions Code): �
Misc.fondufis 8 Condoctors ��
I, ns ownar af ihe property,will do the work and the • • •3 E,5 C�� '
ucture is not intended or offered for sale(Section Other(See Complete Fee Schedulej_ �
7044,Business and Professions Code). Q}'2 7'$�
CONSTRUCTION LENDING AGENCY
i hereby affirm that ihere is a mnstruction lending agenty for
the performance of the work for which this permit is issued - pERMIi ffE- - �� ----�� � �----�-(`�+�+b-TomF)----p� .r � � ------- ��- � -�
(Sec.3097,Civ.C.). `
Pi/kN CHECKING FEE
Lendei s Name ���
PERMIT ISSUiNG FEE �
Lender's Addreu �r f�
I certify iFwl i hove read this applitotion and state ihat ihe � TOTAL FEE $ .JV
abme informotion is correct.I agree to comply with all County
ordinances and State laws regulating Eleciriml wiring,ond
hare6y auihoriie representotives of this County to enter upon
the ove-menti n prop for inspeclion purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
Sig tu of Permiflee� ,r� Dale
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