HomeMy WebLinkAbout0844A � WORKERS'COMPENSATION DECLARATION �'Zo-oow�Pwaia� APp��CAT10N FOR ELECTRICAL P.ERMIT �
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I hereby affirm thot 1 have a cen`rfimte of consent to self CF.-8�5G
� insure,or a certificate of Workers'Compensation Ins�rance, CO.UNTY OF LOS ANGELES DEPT.OF PUBUC WORKS
+ or a certified copy there f(Sec.3800,�La .C!.,.) > �
� Policy No�Company,T'���//�.YI�C. fOR APPtICANT i0 FIEACH NO. FEE DDRE55 7 / �C
�Certified copy is hereby furnished. New Residentiol Bldgs.&Pools
� �ertified capy is filed with the coumy building inspec- 1&2-Family,Sq.Ft. $ _ $ ��CA��TY O��h �
fion depariment. M�Iti-family Sq.R. NEARES7
f� � �� �����LJ�� CRO55 ST.
Dote v�" L2L—A licpnf Residential Swimming Pools OWNER OR
PP FIRM NAME ,lT�C=
CERTIFICATE OF EXEMPTION FROM WORKER$' Outlets:Rec �—Ligh1_Sw._ �'�� � �f
COMPENSATION INSURANCE ADDRE55_ SI �
First 20 QTY - ��-s� Tel.No.� �
(This seclion need nof 6e complefed if the work iovolved by Total No. Additional '�"lC�
fhe permit is for one h�ndred dollars(57D0)or lass.) RLAN CHECK
I certify Ihal in 1he performance of ihe work for which this APPUCaNT 1 i��� .� �-'�'
permit is issued,I sholl not employ any person in any manner ��ghfing Fixtures Plrsf 20 AD�RESS y ,// K/�
so as to become subiect to the Workers'Campensation Laws. S� d�'.,�fY
Additional
� Total No. QTY � : . �� el.No. J J-
Date Applimnt Fixed Appliances Not Over 1 HP PERnniT �'y �
NOTICE TO APPLICANT: If, affer making ihis Certificate of APPUCATION -)'?/��Afr� C� ��
Exemption, yo� should become su6jecl to the Workers' Range— Heater—D.W.— r
ICompensation provisions of the Lahor Code,you m�st forih- Oven _— Dryer —W.M.— ADDRE55
i �with comply Ih suth provisions or ihis permit shall be Top — FAU —W.H.— �
deemed revoked. � Hood — Fan —Other— CITY Tel.No.
'i - - . IfCENSED CONTRACTORS DECLARATION- � - Disp. — Room Air Cond. — ucENSE OR -
�I here6y affirm ihat I am licensed under pro4isions of Chapter 9 REG.NUMBER �L4 � Class.
� '(mmmencing with Section 700D)of Division 3 of the Business Power Apparatus&Larqe Appliances DISTRICT NO. PROCESSED,&Y a
and Professions Code,and my license is in tull force and effeci. �� �
�l� /� Size 8 Type HP,KW,KVA,or KVAR � � �l..�,
I License Number "������ Lic.Class�_..L_ Up to 1 Ind. F�NA� ��7� U
DATE ����i/ �
� ���C� /�� ^�� Over 1 to 10 Incl. U�—_ VALIDATION 0
Coniractor �� Date Over 10 ro 50 Ind. V
❑ FINAL
� I am exempt under Sec. Over 50 to 100 Inc. BY '��y_,1 a
Over 100
B.BP.C.for this reason .(A
dervices,Sw6d.,MCC&Panelboards : � z
� Date: 0-200 Amp.Under 600 V
� Signature 201-1000 Amp.Under 600 V
O Over 7000 Amp.or Over 600 V
i Exemption for Reg.Maini.Elect. /
� , SINGLE fAMiLY : Temp.Power Pole 8 Appurtenances /
HOME OWNER-BUILDER DECLARATION
S `-Sign with One Branch Circuit
� I hereby affirm�ha�I am exempt from ihe Contractar's License
� �Law for the following reason (Seclion 7031.5, Business and Hdoiiiona�Sign o�anci�Cirwita
� Professians Code): , �'„3{,� �p�'�'S �, d �Q�� u ��•.
. Misc.Conduits&Conducfors `�
❑I,as owner of the property, will do the work and Ihe ' �!�,.� ° � ,.G
siructure is not imended or offered for sale(Seciion 7044, ; � Other(See Complete Fee Schedule)—'
8usiness and Professions Code�. - , ' a � � �s-�,
.:�l�i
CONSTRUCTION IENDING AGENCY � �
I hereby affirm that there is a construction lending agency for ' �O �' � � v�J(,?i
'ihe performance of the work for which this permit is issued �, PERMIT FEE (Sub-Total)
(Sec.3097,Civ.C.). �t'•,� j ""t:'�
' . PLAN CHECKING FEE
Lender's Name ' � pERMIT ISSUING FEE � �
Lender's Address _
I certify that I have read ihis application and state Iha�ihe � TOTAL FEE -
i above information is correU.I agree to comply with all Counry .. �o�-� ,
Iordinances and State laws regulaling Electrical wiring,and � /
I hereby authorize representatives of this Covniy to enter upon .
fhe above-mentioned pro erty for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE
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