HomeMy WebLinkAbout1546AWORKERS'COMPFNSATIONDECLARATION CE -806G 2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers' Compensation Insurance, or
a. certified copy thereof (Sec. 38.00, Lab. C.)
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FOR APPLICANT TO FILL IN
Policy No: -41,,Hm(1a1C5 --
New Residential Bldgs. &Pools EACH
[J -Certified copy is hereby furnished.
1 & 2-Family,Sq. Ft. $
f
Multi -family Sq. Ft.
Certified copy is filed with
t4)).", my buifldti pection
Residential Swimming Pools
department.
DISTRICT NO.
=s
Applicant Date
Outlets: Rec.—Light_ Sw._
'
- First 20
CERTIFICATE OF EXEMPTION FROM WORKERS'
Total No. Additional
COMPENSATION INSURANCE
-
t
(This section need not be completed if the work involved
Lighting Fixtures First 20
by the. permit is for one hundred dollars ($100) or less.
Additional
Total No.
j I certify that in the performance of the work for which this
Fixed Appliances Not Over 1 HP
{ permit is issued, I shall not employ any person in any manner
{ so as to become subject to the Workers' Compensation Laws.
Range_ Heater— D.W. _
n.ron _ Dryer _ W.M.
Top _ FAU _ W.H.,_
Date Applicant
III
Hood —.Fan —Other-
-NOTICE TO APPLICANT: If, after making this Certificate of
Disp. _ Room Air Cond._ I _
L:xemption, you should become subjectto the Workers'
{.
Compensation provisions of the Labor Clode, you must forth-
Power Apparatus & Large Appliances I
with comply with such provisions or this permit shall be
Size &Type HP, KW, KV A, or KVAR
deemed revoked.. Y
Up tolIncl.
111111
i-�ir�^' Over 1 to 10 Incl.
LICENSED CONTRACTORS DECLARATION
i Over 10 to 50 Incl.
- I hereby affirm that I am licensed under provisions of Chapter
Over 50 to 100 Inc.
9 (commencing with Section 7000) of Division 3 of the. Busi-
Over 100
ness and Professions.Code, and my license is in full force and
effect.
s Services
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`
0-200 Amp. Under 600 V
r
License Numb r Lic. Class
1
201-1000 Amp. Under 600 V
I Contractor • / r 7 t' A" Date i' tfGz
Over 1000 Amp. or Over 600 V
HOME OWNER -BUILDER DECLARATION
¢ Temp. Povver Pale & Appurtenances
f
with One Branch Circuit
i I hereby affirm that I am exempt from the Controctor's
.Sign.
A .,,.I, r;,..,,;.�
License Law for the following reason (Section 7031.5, Busi-
o-
ness and Professions Code):
Misc. Conduits & Conductors
1 1, as owner of the property, will do the work and the
i. Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
(,
7044, Business and Professions Code).
{G .
CONSTRUCTION LENDING AGENCY
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I, hereby affirm that there is a construction lending agency
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for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
i.
I certify that I have read this application and state that the
. above information is correct, I agree to comply with all County
'. ordinances a fl State law ' regulating Electrical wiring, and
j hereby auto i "-p—n tives of this County to enter upon
the ahove n ned ¢r ty for inspection purposes.
Stznature f Permittee Date
's
PERMIT FEE (Sub -Total)
PLAN CHECKING FEE (One -Fourth Permit Fee)
PERMIT ISSUING FEE
TOTAL FEE
SIiEREVERSE FOR EXPLANATORY LANGUAGE
JOB
DDRESS
ADDRESS ,�
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LOCALITY
NEAREST
CROSS ST s,;t^I
OWNEROR
// 1
FIRM NAME
Tal No.', r�
MAIL
AD D R ESS
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CITY
Tel No.
ADDRESS
CITY
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PERMIT
APPLICANT t1...
CITY
Tal No.', r�
LICENSE OR
.- .
REG. NUMBER
Class
'= Class
DISTRICT NO.
PROCESSED BY
FINAL
DATE
VALIDATION
FINAL
BY
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