HomeMy WebLinkAbout7108AWORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
insure, or 1 certificate of Workers' Compensation Insurance,
or ertifieed copy thereof (Sec. 3800 b- C.)
joItOS%yj :C2 ompany
Certified copy is hereby furnished.
Certified copy is filed a count s ac-
tion department.
Dote la-10-% Applicant
CERTIFICATE OF EXEMPTION FROM WORK RS'
COMPENSATION INSURANCE
This section need not be completed if the work lnwfved by
the permit is for one hundred dellen ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certifimte of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that f am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number '!{oj g2 Lic. Class''C,(f0
SgogsP f"CT o,. -/0• Contractor -Date
1 am exempt under Sec.
B.&P.C. for this reason
Exemption for Reg. Moint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the properly, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Ci, C.).
Lender's Name
Lender's Address
1 certify that I have read this application and state shot the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby aut epreseves of this County to enter upon
above n ned propert for inspection purposes.
tgno bre of PermitteSeVDate
E-906 '
0'81
CE -9060 APPLICATION FOR ELECTRICAL PERMITC
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
New Residential Bldgs. &Pools EACH NO.
1 & 2 -family, Sq. Ft.. %;ZL'T) $ —
FEE
JOB r l
ADDRESS 0OCVJ
LOCALITY i /YIO N
O 7 G V /
Q
Multi -family Sq. Ft. — NEAREST ^
CROSS ST. 1-J Qj;! A41 EOWNERResidentialSwimmingPoolsOR
FIRM NAME G41v L / L
Outlets: Rec_Light_Sw._ MAIL
First 20
ADDRESS
Total No. Additional CITY Tel. No.
PLAN CHECK
APPLICANT
Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
Range_ Heater_D.W. _ APPLICANT C4 VA 6 F1 E'C-f=/(, NC
Oven _Dryer _W.M._ ADDRESS 1-73 N U A/LC WaTop _ FAU _ W.H. _
Hood _ Fan _ Other—
ppCITY !-L./) /) Cr4 Tel. No. rfl
Disp. _ Room Air Cond. LICENSE OR
REG. NUMBER Class. C`/D
Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY
Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE a p p /
Over 10 to 50 Incl. FINAL
VALIDATION
Over 50 to 100 Inc. BY
Over 100
Services, Swbd., MCC & Ponelboards
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits z 7 1 p, 8 A
Misc. Conduits & Conductors' 2
Other (See Complete Fee Schedule)_ s 5850
e e'r Lw 5OL
2 1 0-84PERMITFEE(Sub-Total) p0
PLAN CHECKING FEE
PERMIT ISSUING FEE U
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
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