HomeMy WebLinkAbout1439A (8) ,WORKERS'COMPENSATION DECLARATION �bA�3 ���A, qpp��CATION FOR ELECTRICAL PERMIT �
�i hereby affirm ihat I have a certificate of mnsem to self Ce�806G y�/�
/�
insure,or,a cenitimte of Wo�ke�s'Compensauo��os��ance, COUNTY OF LOS ANGELES BUILDING AND SAPETY �
or a certified copy thereof(Sec 38D0,Lab.C� �,.,/
Policy No�������ompany �P'�'/r�[.�.i�OFyar�4.-' FOR APPLICANT TO FILL IN JOB
� Cerhfied ropy is hereby furnished. p/6V�Cfi New Residenfial Bldgs.& ool; EAC NO. FEE ADDRE55�� �� i // �P'�
� Certified topy is filed with the county building inspec- 1 &2-Fomily,Sq.R.� $ — � �OCALITY�' G
1 gp rimen�. ,vq�,/� Multi-fomily Sq.Ff. — NEAREST
Date ��r�Applimnt�„��� � '„TuL�d'.. Residential Swimming Paols OWNER OR �
FIRM NAME �-
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Ligh�_Sw._ ��� ii </
COMPENSATION INSURANCE First 20 ADDRE55��.S /°..a
(This section need not ba compleled if fAe work involved by '� Gry}A
}he permit is for one hundred dollars(SI00)or less.) Total No. Additional CITY �:�" � Tel.No �J
I certify that in the performance of the work for whith ihis PLAN CHECK
ermi�is issued,I shall not em lo an APPLICANT
p p y y person in any manner
so as�o bewme su6ject lo the Workers'Compensation Laws. �ighting Fixtures Pirst 20 AD�RESS
Totpl No. Additional
CITY Tel.No.
Da�e Applimnt Fixed Appliances Not Over 1 HP FERMIT /�
Nr' �TO APPLICANT: If, ofter making this Certificale of APPUCANT�� �(,7 —� �� �. (_
Ex �Nion, you should hecome subject to the Workers' Range_Heater_D.W._
Compensation provisions of fhe Labor Code,you m�st forth- Oven _Dryer _W.M.� ADDRESS � 1�x. �[
ith comply ith such provisions or this permit shall be Top _FAU —W.H._
deemed revoked. Hood _Fan _pther_ CITY �h,,,�a Tel.No.��f���j,,
LICENSED CONTRACTORS DECLARATION LICENSE OR � /v
Y P P Disp. _Room Air Cond. — I' "� C�os J
I hereb aifirm thot I am licensed under rovisions of Cha ter 9 REG.NUMBER za"` �
(commencing with Sec�ion 7000)of Division 3 of ihe Business DISTRICT NO. PROCESSED BY
ond Prafessions Code and my license is in full force and effect. Power Apporotus&Large Appliantes 2�
Size&Type HG,KW,KVA,or KVAR � �
License Number ��� � Lic.Class��� o Up�0 1 Ind. FINAL '(�
Over 1 to 70 Ind. DATE � �� ,� (�
�� Coniracbr��������— Dote � � Over 10 to 50 Ind. " �,� VAtIDAT10N ti
� fINAL �
I am exempt under Sec. Over 50 to 100 Inc. gy
Over 100 �'��✓ N
8.8P.C.tor this reason L
� Date: �Services,Swbd.,MCC&Panelboards �
0-200 Amp.Under 600 V
Signoture 201-1000 Amp.Under 600 V
❑ Over lOpO Amp.or Over 600 V
Exemplion for Reg.Mqint.Elect.
� SINGLE PAMILY Temp,Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
l.,; $ign with One 8ronch Circuit
.,:by affirm thot I�m exempt from the Contra<tor's License r�
� � .� r �i ArI.J��;nn�l C;y.,R.C.^.:�:Cif^.Uif� i I GL.) Y�.
- -- - wi��y reason(Seciion%VJI.�, [S�Sine55 pl1C � �p p o e o`�
Professions CodeJ: .
❑ I,as owner of the o ert ���Misc.Conduits 8 Conductors
pr p y,wiil do the work and the .Other(See Complete Fee ScheduleJ_ , � � 0 y�•9�
strutiure is not intended or offered for sale (S?ction
7044,Business and Professions Code). .,�� „���y�i
CONSTRUCTION IENDING AGENCY
I hereby affirm thot ihere is a construction lending ogency for �Q�� �'"'8 7
ihe perform�nce of Ihe work for which ihis permit is issued PERMIT FEE (Sub-Total) .� �
(Sec.3097,Civ.C.).
� PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING PEE � ��.
Lender's Address
I ceriify that I have read Ihis applimtion�nd state ihat ihe TOTAL FEE ��
above informalion is corred.I agree to comply with all County
ordinances and Slafe laws regula�ing Eleclrical w ring,ond
hereby authorize represento�ives of this Co�nty to enter upon
�the bave-menrioned property for inspedion po oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
� ` � � �1�
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