HomeMy WebLinkAbout5819AWORKFRS',C0MPENS.4TIOte DECLARATION 76A663 APPlICATIO%I FOR ELECTRICAL PERMITCE -806G (2:80)
I hereby affirm that I have a certificate of consent• to self COUNTY OF LOS ANGELES
BUILUINs
GNDdxFETY «
w
insure, or a certificate of W'orkers', Compensation Insurance, or
a certified copy thereof (Sec 3800;- b. C) - .. _..-. rFOR APPLICANY"Y6"1LL 1't7`-` JOB - Ci,t Q.
Policy No. Coritpan ' - -" "'""'"" ""'-" EACH NO FEE ' G
C New Residential Bldgs. & Pools
ADDRESS
Certified copy is hereby furnished. be -A- - 1 & 2-Family,Sq. Ft. _ -
LOCALITY
1 & 2 -
family ;Sq. Ft.
N AECertifiedcopyisfiledwiththe-cotinty building inspection CResidentialSimmingPoolsO
department. . FEG^'v
Date ® pplican Outlets: Rec. Light_ Sw._ MAIL
First 20
ADDRESS
CERTIFICATE OFEXEMPTION FROM WORKFRS Total No. - Additional / S CITY Tel No.
0.
COMPENSATIM' SUY2 AI .E`' PLAN CHECK -..-.,. - «...:...,..,.. _..,,. C)
APPLICANT U
This section need not: be, cotnpleted if the work involved Lighting Fixtures First 20 ADDRESS AbythepermitisforoneHundreddollars ($100) or less.) Additional M.w.m.
Total No. CITY Tel No. UIcertifythatintheperformanceofthe, w;orkfor which this Fixed Appliances Not Over 1 HP — PERMIT RJpermitisissued, I shall not employ any person in any manner-
so as to become subject to t e Workers' Compensation Laws. Range_ Heater_ D.W. _ APPLICANT 3"TLi). C -
v
Oven _ Dryer _ W.M. _ ADDRESS (
l7 '
Z
N h .. Top — FAU _ W.H. _ ... Tel
Date Appi' n CITY f Tel No. 7
Hood — Fan _Other
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond.—
LICENSE OR _
R . NU RARER
Exemption, you should ;become subject to the. Workers' - DISTRICT NO. NO. PROCESD BY
Compensation provisions of the Labor, Code, you must forth- Power Apparatus & Large Appliances
with comply with such provisions or this, permit shall be Size & Type HP, KW, KVA, or KVAR
deemed revoked. - U to 1 Incl
LICENSED.CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license_ is in, full force and
effect.
C
License r (
r
Lic, Class
Contra to - v a[e IOn'X>>
HOME OWNER-BUILDFR.DEC LARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
I, as owner of the property, will do the work and the.
structure is not, intended.,or offered for safe (Section
7044, Business and 'Professions Code) —'-'•
CONSTRUCTION L,F-NDING,AGENCY „
I hereby affirm that there is a,.constr'uction lending agency`"
for the performance of the work, hicli[h s permit is
issued (Sec.ec..3.3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state [hat the _
above information is correct. I agree to comply with all County
ordinane and State laws regulating Electrical wiring, and
hereby' uth rize representatives of this County to enter upon
the ove-mentioned pr ty for inspection purposes.
x,13-17
TNdature of Permitte . Date:'
P FINAL
Over 1 to 10 Incl.d DATE VALIDATION _
Over 10 to501nc1."
FINAL
Over 50.to 100 Inc.- By
Over 100 — :Ii
Services
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 CfFouits, ,.
Misc. Conduits &, Conductors
Other ISee Complete Fee Schedule)—
PERM IT FEE (sub-Totalj Qd
PLAN CHECKING FEE (One -Fourth Permit Fee)
pJ
PERMIT ISSUING FEE. - -,-
TOTALFEE.
SEE REVERSE FOR EXPLANATORY LAhCUACE 4„ _
r. C 80
APPROVALS DATE INSPECTORSSIGNATURE I
TEMP. POWE.P POLE
FUNUEISLge WORK;=
ROUGH CONDUIT
0
WI RI NG -- -
l! r:xTURES
P.OWER.AUTHORIZED
UTtLITV CO. NOIFiED
ii-~ EINAL Pi6^,.1,f/L O.Z. 14004
OWNER•13UTLDER DECLARATION
hereby affirra 8iat 1 am exempt from the Contractor's
License Law for the following reason (Secifon 7031.5,
Btaseness and '?>efetsnons Code): Any city or county,
whtrh require; a permit to construct, atter, improve,
demolish, or repair any structure, prior to its issuance,
also requires the applicant for, such, permit to file a
signed . siatement that he is licensed pursuant to the
propmons of the Coatractor's License Low (Chapter 9
cotrimencinp, with Section 7000) of Division 3 o the
Business and Professions Code) or that he is exempt
th:refmm and rhe basis for the alleged exemption. Any
violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil perairy of nor more titan.
fire hundred dollars (3-500).: -
I, as owner of the property w:?t de thes:^oik, and
NOTES the structure is, not intended or aff,,d for sate.
Sec. 7044, Business and Professions Code: .Tire Con-
trcttWLaw d ofLicense ,,.oes not apply to an owner
j5r°i ei y who- uilds or improves thereon, and who does
N, :9..eC, .. such wok himself provided rho! such imp aremen:.s
ar not intended- or offered for s.JL. if, aowever,are
building or improvement is sole w-i0dr, one . year o
complefron, the owner-buiider will have the burden
proving that he did not_ build.. or, impra ve for the
purpose of .sdie.) .
am ezemp2 under SeC.
B & P.C. for cls reason —
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