HomeMy WebLinkAbout0891A (4) WORKERS'COMPENSATION DECLARATION � 76n663 �a,e� APPLICATION FOR ELECTRICAL PERMIT �
1 hereby af(irm that I hove a certifica�e of consent to self � CE-806G
insure,o�a ce�iificore of Woike�i Co�.+pe�sa�io��osura�ce, , COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy Ihereof(Sec.3800,Lab.C.)
POolfty ND. COmpony FOR A►PLICANT TO FRl IN DDRESS O3S �S�1 N ���- �
Cer�ified copy is here6y furnished. New Residential Bldgs.8 Paals EA�H NO. FEE
� Certified copy is filed wirh the county buiiding inspec- 1 8 2-Family,Sq.Ft. S — E LOCALITY (,JQ�h�—
tion deporiment. � Mulli-family Sq.Ft. — NEAREST n
Residen�ial Swimming Pools OWNER OR �� ���
Oate A licont �
PP . /G ��� .�y� FIRM NAME FQ�.f.�N �GF 7C�C4GL
CERTIFICATE OF E%EMPTION FROM WORKERS' hF LO( Nait
COMPENSATION INSURANCE Oullets:Rec_lighl_Sw._ ��� � � qDDRE55
f� First 20 �7� �� � �
' (This fsction need not hs complated i(fh�work involvod by �"Z Addi�ional •� 3/ no CITY�/nJ4$ a�z+�TiLf TeL �-_
I the permit is for ona hundred dollar�(S100J or lass.) To�al No.
F, 1 certif thol in the eriormance of ihe work for which this _ PL4N CHECK
( Y P APpLICAM .�. ���LG.
` permit is issued,I shall nai employ ony pe�son in any manner .']f , � �
� so as to become subjec��o the Workers'Compensofion Laws. lighting Fiz�uses First 20 � ' ADDRESS ' .
� Additional
, To�ol No.J CITY �.uT/1 A Tel.Na ,$S7J-9ZJ3
r DO�e �PP11CO"� Fixed Appliances Not Over 1 HP PERMiT
i NOTICE TO APPLICANT: If, after moking this Certi(imie oi . AP�LifANT
Exemplion, you should become Subject fo the Workers' Ronge_Heater_D.W.—
j Compensation pro��sfons of�he Labor Code,you musl for�h- Oven _�ryer _W.M.— ADDRESS -
I with comply wlh such provisions or this permi� shoil be Top —FAU _W.H.—
deemed revoked. , CITY Tel.No. -
UCENSED CONTRACTORS DECLARATION Hood _Fon _Olher— _
Disp. _RoOm Air Cond. — LICENSE OR Class.
I hareby affirm that I am licensed under provisians of Chopter 9 . REG.NUMeER
(commencing with Seclion 7000)of Division 3 of the Business power Apporatus 8 large Applionces DISTRICT NO. PROCESSED BY r
ond Prolessions Code,and my license is in full force and effecl. y
Size 8 Type HP,KW,KVA,or KVAR /� 0
lice�se Number Lic.Closs - � Up fo 1 Incl. �•`� � / � FINAL " V
� _� Over 1 to 101nd. � DATE VALIDATION �
Controc�or Date Over 10 to 50 Incl. ' O
QFINAL ~
I om e*empf�nder Sec. Over 50 fo 100 Inc. BY uVi
B.BP.C.for this reason Over ioo �G°9.1 A� �
Services,Swbd.,MCC 8 Panelboords I�, � ► - ��s � � e'� � Z
Date: 0-200 Amp.Under 600 V � DV -
Signoture �� -201-1000 Amp.Under 600 V � ��� � � � •>7��J �
❑ Over 1000 Amp.or Over 600 V OJe D N
Exemption for Reg.Moinf.Elect. •J 7 Ci a,�i�
SINGLE FAMILY Temp.Power Pole 8 Appartenances l L�' ���� /��_G—,��'.�
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circoir
I hereby afiirm thol I om e.empt from the Controdor's License Addi�ionol Sion Bronch Circuits
low for the foilowing reason($ection'071.5,6usness and IU �— p
Proiessions Code�: .� �
❑ I,as owner of the properly,will do 1he work ond the Misc.Conduits 8 Condutlors �
structure is no�intended or oflered ior sale(Settion Other(See Gamplete Fee Schedule)_
70-04,Business and Professions Code). - �
,�
� CONSTRUCTION IENDING AGENCY . - � . . _ �
I hereby affirm rhof rhere is a consnuttion lending ogency for 0
the performance af ihe work for which this permil is issued PERMIT FEE �� � � � (Sub-Total) ` . . . .
�Sec.3097,Civ.C.J.
PIAN CHECKING FEE- � -�� S�D . - ... .. . . . . .
lender's Nome
PERMIT ISSUING FEE __ � ` -. �
Lender's Address � �-
I ceriify�ha1 I hove read�his applicatian and slale Ihal the TOTAL FEE
obove inFormaf�on�s correct.I ogree io comply with all Coun�y I � �
ordinances and State laws regolaiing Electrital wiring,ond � • �
hereby outhorize representotives of this Counly lo enler�pon � �� ',
Ihe obove-meNioned proper�y!or inspeuion purposes. '',
SEE REVERSE FOR EXPLANATORY LANGUAGE .
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