HomeMy WebLinkAbout1773AWORKERS'COMPENSATIONDECLARATION
CE -806GCE -806G (2-801 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to self
insure, COUNTY OF LOS ANGELES BUILDING AND SAFETYoracertificateofWorkers' Compensation Insurance, or
a certifiedd/
fir"
op tthhe reof (Sec. 380 . C.) n
V lK FOR APPLICANT TO FILL IN dR
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Certified is hereby
New Residential Bldgs. &Pools EACH NO. FEE ADORES /4 I
copy furnished. 1 & 2-Famil S Ft. $ — v. q• LOCALITY MQ
Certified copy 6 filed with the count building inspectiony
Multi -family Sq. Ft. — EAREST
g
P lY
Residential Swimming Pools CROSS ST
OWNER OR 1T
Date Applicant s nI/ / / FIRM NAM 6
Outlets: Re Light w Svvfl O nnU 1 O MAIL-y-e—
CERTIFICATE OF EXEMPTION FROM WOR KEKS' t First 20
Total No. I
ADDRESS
COMPENSATION INSURANCE Additional CITY Tel No.
PLAN CHEC
aThissectionneednotbecompletediftheworkinvolvedAPPLICANT1
by the permit is for One hundred dollars ($100) or less.) Lighting Fixtures First 20
ADORE U
I certify that i, the performance of the work for which this
Total No._ Additional
Fixed Appliances Not Over 1 HP CITY Tel No. A x-7(77 QpermitisIssued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. Range_ Heater D.W. - - PERMITPERMAPPL,I ANT -- U
Oven ` Dryer _ W.M. _ ADDRESS Li! 0-
Date Applicant Top _ FAU _ W.H. _ Z
Hood _ Fan CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of
Other _
Dlsp. Air Cond.— LICENSE OR ^ Exemption, you should become subject to the Workers Room
REG. NUMBE 3 Class ' Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY
deemed revoked. Size & Type HP, KW, KVA, or KVA
OUpto1Incl.
LICENSED CONTRACTORS DECLARATION
Over 1 to 10 Incl.
Over 10 t0 50 Incl.
FINALDATE '/ p VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY 1
ness and Professions Code, and my license is in full force and
effect.
gx— License Number' Lic. Class
Services
0-200 Amp. Under 600 V 1
It
j y y_
Contracfj(:/y / ;W 1
201-10 Amp. Under 600 V t
ipateaOver1000Amp. or Over 600 V
HOME OWNER -BUILDER DECLARATION Temp. Power Pole & Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Bud- Additional Sign Branch Circuits
tress and Professions Code):
Misc. Conduits & Conductors
1, as owner of the property, will do the work and the Other ISee Complete Fee Schedule)— structure is not intended or offered for sale (Section
7044, Business and Professions Code). 9 i 7 7.3 A
CONSTRUCTION_ LENDING AUENCY
1 hereby 6.0eaffirm -that there is a construction lending agency-
for the performance of the work for which this permit is
issued (Sec: 3097;'Civ. C.). PERMIT FEE Sub -Total) - f e *5670
Lender's Name—.
PLAN CHECKING FEE (One -Fourth Permit Fee) a 5 b 7 0 =
Lender's Address
PERMIT ISSUING FEE 03.08-82
I certify that I have read this application and state that the TOTAL FEE s t0 10aboveinformationiscorrect. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize, representatives of this County to enter upon
the ve- en ned property for inspection purposes.
SEE'REVEKSE FOR EXPLANATORY LANGUAGE
Sig tur f Permittee Date
l i