HomeMy WebLinkAbout3948AWORKERS'COMPENSATION DECLARATION zo-amvDPW ase] APPLICATION FOR ELECTRICAL PERMIT O6A063
I hereby affirm that I have a certificate of consent To self ceaoac;
insure,ora certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
or a certified copy thereof(Sec.3800,Lab.C.)
9 Policy No. Company FOR APPLICANT TO FILL IN
ADDRESS k' •1 'C.
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO, FEE
Certified co is filed with the count building inspec- 1&2-Famil S Ft, LOCALITfD %,
e
PY Y 9 P y' q' NEAREST
tion department Multi-family Sq.F1. CROSS ST.
Residential Swimming Pools O'NNER OR
Date Applicant C> LnJ FIRM NAME
MAIL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light_Sw— DRESS O
7A
COMPENSATION INSURANCE First 20
This section need not be completed if the work involved by Total No.-- Additional
the permit is for one hundred dollars($100)or less.) PLAN CHECK
j I certify that in the performance of the work for which this APPLICANT
I permit is issued,I shall not employ any person in any manner
Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Law.
r Additional Tel.No j (y•Total No. CITY
Date Applicant 1-IL Ls Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION e.
Exemption, you should become subject to the Workers' Range— Heater—D.W. —
Compensation provisions of the Labor Code,you must forth- Oven — Dryer —W.M.— ADDRESS
l with comply with such provisions or this permit shall be Top — FAU —W.H.—CITY Tel.No,
ideemed revoked. Hood — Fan —Other—
LICENSED CONTRACTORS DECLARATION Disp. —Room Air Cond. —
LICENSE OR Class.
it hereby affirm that I am licensed under provisions of Chapter 9
REG.NUMBER
commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances I DISTRICT NO. / PROCESSED BY
and Professions Code,and my license is in full force and effect.
Size&Type HP,KW,KVA,or KVAR O
License Number Lic.Class FINAL
U
Up to 1 Incl.
DATE
i Over 1 to 10 Incl. C/ a VALIDATION
Ij Contractor Date Over TO to 50 Incl.FINAL
I am exempt under Sec. Over SO to 100 Inc. BY LUW
B.&P.C.for this reason
Over 100
Z
Date:
Services,Swbd.,MCC&Panelboards Z
0-200 Amp.Under 600 V {
Signature 201-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V t
Exemption for Reg.Mains.Elect. I 4.G A.
SINGLE FAMILY Temp.Power Pole&Appurtenances
If HOME OWNER-BUILDER DECLARATION i w m u o 2
I herehy affirm that I am exemol from the Contractor's License
Sign with One Branch Circuit
r Additional Sign Branch CircmisLawforthefollowingreason(Section 7031.5, Business and I a'v.J U
Professi -Code):
j I,as owner,of the property,will do the work and the s Misc.Conduits&Conductors y r" `-'U"0structureisnotintendedorofferedforsale(Section 7044, y Other(See Complete Fee Schedule)_; l'J Z.Q-4"8 8
Business and Professions Code). i
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 x PERMIT FEE Sub-Total) a GV
Sec.3097,Civ.C.1.
i PLAN CHECKING FEE
Lender's Name SPERMITISSUINGFEEU
Lender's Address GO t5 z'
I certify that I have read this a lication and state that the 1 TOTAL FEE
1
above information is correct.I a ee to comply with all County
ordinances and Slate laws reg luting Electrical wiring, and
ereby au horize re esentatw of this County to enter upon
t e above a yi e' property o" pection purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignature of Permittee Date
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