HomeMy WebLinkAbout0674A (4)WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure,
�- 1 oorpya certificthereate of Workers' Compensation Insurance, or a certified
r� cof (See. 3800,Lab. C.)
Policy No. 716Tompany !RM ins ' canGe
® Certified copy is hereby furnished.
® Certified copy is filed with the coon Ir'huildin inspection
ndepartment.
Date7� Applicant
CERTIFICATE OF EXEMP ON FROM WORKERS'
COMPENSATI NINSURANCE
(This section need not be completed if the work involved by the
permit Is for one hundred dollars ($100) or less.)
1 certify that In the performance of the work for which this permit
is issued, I shall not employ arty person in an In
so as to
become
subject
to� the Workers' Compensati ws�Workers'Compensation Dale) 77 ApplicantNOTICE TO APPLICANT: II, r maExemption, you should become su ject to t
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that.1 am licensed -under provisions of Chapter 9
(commencing With Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
78-883 10191
CE -8080 APPLICATION FOR ELECTRICAL PERMIT {j
u
COUNTY OF LOS ANGELES BUILDING AND SAFETY
)�
FOR APPLICANT TO FILL IN ADDRESS 0_6j,(��'+�-/y(Jr
New Residential Bldgs. & Pools EACH NO. FEE
Dt
1 & 2 -Family, Sq. Ft. 5 — S LOCALITY county Of L.A.
Multi -family So. Ft. NEAREST
CROss SL Lemon
Residential Swimming Pools
OWNER OR
nRMNAME Cummins Electric
Outlets: Rec— Light _sw.— DDREss74-133 El Paseo Ste.10
First 20,
Total No. Additional CITY Palm Desert Te1•1619568907
Lighting Fixtures First 20
Total No. Additional
Fixed Appliances Not Over 1 HP
Range_ Heater_ D.W. _ -
Oven _ Dryer _ W.M.
Top — FAU _ _ W.H.
Hood — Fan _ Other_
Disp. — Room Air Cond. _
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
License Number 447384 C-10
Lic. Class
Up to I Incl. -
Over 1 to 10 Incl.
Contractor Rnmmi ns Flc+ Dale
- - -- --
Over 10 to 50 Incl.
❑ I am exempt under Sec.
_ Over 50 to 100 Inc.
B&P.C. for this reason
Over 100
Services, Swbd., MCC & Panelboards
Date:
0 - 200 Amp. Under 600 V
Signature
201 - 1000 Amp. Under 600 V -
1000 Amp. or Over 600 V
❑Over
Exemp. on for Reg. Maint. Elect.
SINGLE FAMILY
Temp. Power Pole 8 Appurtenances
HOME OWNER -BUILDER DECLARATION
Sign with One
Sign with One Branch Circuit
ranch ircuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions
s
Code):
❑ I, as owner of thero rl will do the work and the structure
p y'
Misc. Conduits & Conductors
is not intended or offered for sale (Section 7044, Business
Other (See Complete Fee Schedule)
P
and Professions Codet.
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, 1 PERMIT FEE --
Civ. C.I.
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
1 and State laws regulating Electrical wiring, and hereby authorize
(ADDRESS
CITY - Tel. No.
ADDRESS74-133 El Paseo
CITY Palm Desert Tel.No61956890 4
LICENSE OR
REG. NUMBER - Class.-
DSTRICT NO. PR D BY
-D-4
FINAL
DATE
FINLo � `PSI
BY /
(Sub-Tolalt I I` I— I - -
representatives of this County to enter upon the above-mentioned --- - - -
prop for 'sl{Iecli poses.
... � SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permntee Date
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