HomeMy WebLinkAbout1759AWORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certif//i¢�'�/if copy thereof (Sec. 3800, lab. CAp. )
Policy NOL1L?�Compony '1A
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
ti�o/p epar mens.
�
Date 41 Applicant I Z:*z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by
the permB is for one hundred dollars ($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
f"' TO APPLICANT: If, after making this Certificate of
Ex )1ion, you should become subject to the Workers'
Compensation prowisiors of the Lauur Cude, you rnust forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chopter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, nd my license is in full force and effect.
qp y
License Number ` �3/ Lic. Class
Contractor " lefr 1X'/ `fir'^-' Date �`
❑ 1 am exempt under Sec.
B.&P.C. for this
Date:
Signature
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I'r Saffirre that I am exempt from the Contracto%s License
Lon. ,Sr the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, as owner of the property, 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, Civ. C.).
Lender's Nome
Lender's Address
I certify that I have read this application and state that the
above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby a thn.,` representatives of this County to enter upon
The ab e -mentioned property for inspection pu oses.
Si nature of Parmtttee Date
76A663
E-806 I0i81
OE -896(' APPLICATION FOR ELECTRICAL PERMIT
C
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO
FILL IN
JOB
ADDRESS
New Residential q s. & P
1 & 2 -Family, Sq. Ft. �15C.E�
Multi -family Sq. Ft. _ --
Residential Swimming Pools
Outlets: Rec_Light_Sw.—
First 20
Total No. Additional
Lighting Fixtures first 20
Total No. Additional
Fixed Appliances Not Over 1 HP
Range Heater_D.W. —
Oven _ Dryer — W.M. —
Top _ FAU — W. H. —
Hood —Fan _ Other_
Dis —Room Air Cond. --
P•
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over 1 to 10 Incl.
Over TO to 50 Ind.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Ponetboards
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
Misc. Conduits & Conductors
®Other (See Complete Fee Schedule)_►
EACH NO. FEE
LOCALITY ,t-
NEAREST
CROSS ST.
$ _ ry,
$
OWNER OR
FIRM NAME
MAIL
ADDRE /L7 l7
CI ¢" ` �,�,Tel. No. q
PLAN CHECK
APPLICANT
ADDRESS
CITY Tel. No.
PERMIT �s•r //t / 4
APPLICANT „r" ,f'.y'�G'
ADDRESS
Tel. Nom
CITY �Nd ,.2 �f!
LICENSE OR / VW
_3 Class. ,�7�,,J)
RCG. NUMBER ��e.7u., `'' ")
DISTRICT NO.
PROCESSED BY
FINAL
DAA I L/ -J % VALIDATION
FINAL
BY
r} n o d v o 2
C 7 R
sot, 9742=
q p 8- 8 6
PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE TOTAL FEE
(Sub-Totol)4��e
SEE REVERSE FOR EXPLANATORY LANGUAGE