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HomeMy WebLinkAbout1723A � .;VORKERS'COMPENSA710N�ECLARATION , 76A68� 10/et AppLICATION FOR ELECTRICAL PERMIT �7 I CE-806G I hereby effirm that I have a certiticate o1 consent to self insure, or a certiticate ot Nrorkers'Compensation Insumnce,or a certitied COUNTY OF LOS ANGELES 6UILDING AND SAFETY �j copy thereol(Sec.380D,Lab.CJ �Cy No. � CoinPany FOR APPLICANT TO FILL IN ' JOB Certificd co is hcrcb fwnished. EAGH NO. FEE. ADDRESS � �/ 1' New Residential Bldgs.8 Pools � Certified copy is filed with the tounty buildirg inspection 7&2-Family,Sq.Ft. S — S � LOCALITY Uv� • department.. � �- � Mutti-famiiy Sq.Ft. — NEaHEST � Date � � Applicant Residenlial Swimming Pools � CpwNEa oq `'��'�'' FIRMNAME A�"A�(�� f! t � CERTIFICATE OF ExEMP710N FROM WORKERS' � ` \ �.,ut� � COMPENSATION INSURANCE . . . Outlets:Rec�ght—Sw,y�L- ;' � /� 3� � v� ADORESS (Thla sectbn need not be eomdaled H fha work invdved by the First 20 Total No. Additional - CITY�G� � Tel.tJo-`� permit Ia/or one hundred dollare($100)w�esa.) , . I certify that in the perlormance of lFw vrork tor which this permit . _ . P�� is issuetl,I shall not employ arny person in any manner so as to A��� � 6ecome wbject to lhe Nlorkers'Compensation Laws. � L'ghting Fixtures Flrst 20 ADDRESS � - ���, TotalNo.�_ �itional CITY� Tel.No. Dafe��APplicxnt , Fxed Appliances Not Over 1 HP ���,�� ��37 NOTICE TO APPIICANT: 11, after makinq [his Certificate of PERMIT Exemption,you should become subject to the Wo�kers Compensation Ran9e_Heate�_ �.W. _ nPPLiCANi prov�sions ol the Labor Cede,ynu rm�st ferthv�ith cemp!y rk[h s�_h O�bn_U-yer_ W.M._ ADDRFSS � - provisions or this permit shall be deemed revoketl. _ _ Top .—FAU _ W.H._ _ . . � CITY -- � Tel.No. � . LICENSED CONTRACTORS DECLARATION Hood_Fan _ Other_ I hereby affirm that 1 am I'�censed under provisions of Chapter 9 uceNSE oa (commencing with Section 7000)of Division 3 0l[he Business anC ��sP� —���A����� — REG.NUMBER ' G LL Gass. Rofessions Code,and my license is in full force and eltect. otsrnicr No� P�toCE55Eo Power Apparatus 8 Laige Appliances �� y _` Size 8 Type HP,KW,KVA,or KVAR �p License Number O V� �`7�a Class� �- ' Up to 1 Incl. - - - - - FINAI . � O A7��isre. Over 1 to 10lncl. �A� �ti?/�' VALIDATON � Con!ractorP/2j�/�''T/QM�e Date�� � � pyer 70 to 50 Incl. ! � � � � ❑ I am exempt under Sec. pver 50 to 100 Inc. gyAL I - U�+, B.SP.C.for this reason Over 100 V�' � Services,Swbd.,MCC 8 Panciboards � -- - � � � N - Date: 0-200 Amp.Under 800 V *�" x S�onat��rP, � �, ��201--1000 Amp.Untler 600 V � -� � � - , •�� �2 3 A ❑ � ` Over 1000 Amp.or Over 600 V ' ' ' Exemptan tor Reg.Maint.Elect. t; • • • •2 SINGLE FAMILY - � Temp.Power Pole&Appurtenances f • •�1 Q 2 5 HOME OSNNER-BU!LDER DECLARATION - Sign with One E3ronch Circuit � 1 here6y alfirm that I am exempt from the Contractor's License Law • for the lollowing reason(Section 7031.5,Business and Prolessions Addition=_I Sgn Brarr_h,Circui!s __ __ , _ _ _, _ •Q�,��_ Code): • � Misa Co�uits 3 Co�Muctors I 2 0 3—3 7 I,as owner of Ihe property,witi do Ihe work and ihe structure is not intended or olfered for sale(Section 7044,Business Other(See Comp�ete Fee Schedule)_ � • . antl Protessions Code). - �� � - � � -- - - �- - - � CONSTRUCTION LENDING AGENCY � ... . . . . I I hereby affrm thzt there is a constnxtion IeMing agency for the performa�e o1 the work for which this permit is issued(Sec.3097, pERMR FEE (Sub-Totap �f I Civ.C.1. .. . . . . . � PLAN CHECKING FEE j Lender's Name � PERMR ISSUING FEE ._ _ _ _.. . _ _ � � Lenders Address � I certify that I havo read this app�icatron and state that che above TOTAL FEE information is cormct I agree to compy with all County ordinances �� � � � � � and State laws regulating Electrical wiring,ard hereby authorize , � repr Iztives of this County to enter upon the ebove-mentioned � � '- " � � -- - -- -� - � - pr r/�.s� .\on .po�� ��/��d7 SEE REVERSE FOR EXPLANATORY LANGUAGE TS�gnatUre ot Permitfee Date � ' . _.. . : . ._.... . !ia"' . � __/. r r ' . �- --, ' - i IJ..`.. ,'._-i_- —�"'-_'—_.�_ ; . ' -� . . ! li ' I � �' I ' '1, ' r i ��i , . , i � ; ;�t i � • ; :: , �r. . i � ' i , , � �' . - • ,�-� ! , , � i� , '.��, ;�� i , /i j � ! � � � F � ,� � f. �� �� ( • • I � ;f � .l., i. � 1 i t= : ' '' '! 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