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HomeMy WebLinkAbout1758AWORKERS' COMPENSATION DECLARATION . • I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certif fir thereof (Sec. 3800, LabC.) Policy NWrfO''' Company Certified copy is hereby furnished. Certified copy is filed with the county building inspec- ti%o�n�re�par�m/ent, T Date '" �d� t�'�" Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the work involved by the permit is for one hundred dollars ($700) 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 M' '}. TO APPLICANT: If, after making this Certificate of E: 1tion, 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 I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, andd}m�y license is in full forceandaffect- License Number `,,,.,y`/- _a ' Lic. Class�,=% Contractorc�J(=-�//���� Date � •"'y����;, ❑ I am exempt under Sec. BAP.C. for this reason Date: ❑ Exemption for Reg. Mainl. Elect. SINGLE FAMILY _ HOME OWNER -BUILDER DECLARATION affirm that I am exempt from the Contractor's License Lay. or 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 Name Lender's Address I certify that I have read this application and slate that the above information is correct. I agree to comply with all Courtly ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon th bove-mentioned property for inspection put es. - ,' / Signature of Permiuee Date 6A063 '°'°' APPLICATION FOR ELECTRICAL PERMIT CE -806(' COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN f08 „„"" . /:? -10 New Residential Bldgs. 92o1 o� EACH Y• Sq. NO. FEE 1 & 2-Famil Ft. $ — S 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— Disp. _ Room Air Card. — Power Apparatus & Large Appliances Size & Type HP, KW, KVA, or KVAR Up to 1 Incl. Over I to 10 Ind. Over 10 to 50 Incl. Over 50 to 100 Inc. 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 >. Power Pole & Appurtenances with One Branch Circuit iionai Sign Branch Circuits Conduits & Conductors r (See Complete Fee Schedule)_ LOCALITY //C.� NEAREST ��— CROSS ST. OWNER OR FIRM NAME MAIL 'j4 -f ADDRESS CITYay11_19_// it_14 T.I. N PLAN CHECK APPLICANT ADDRESS CITY Tel. No. PERMIT APPLICANT ADDRESS . G� • r�J.7L ,��/ CITYr �Arf ))J�TeI. No.t�J9� Class. PERMIT FEE (Sub -Total) PLAN CHECKING FEE PERMIT ISSUING FEE /r r TOTAL FEE SEE REVERSE FOR EXPLANATORY LANGUAGE % LiS—.Jr 7 VALIDATION FINAL BY 0 217u8A $ o-eae2 i 121.10 2'1.16 ©9. 8-86 a 71 ii 7, F! 43 i ti T cL cl.