HomeMy WebLinkAbout0990A (2)WORKERS' COMPENSATION DECLARATION 76A663 10,81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE -806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100) or less-)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Lows.
Date Applicant
NOTICE TO APPLICANT: if, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I 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 farce and effect.
License Number Lic. Class
Contractor
❑ I am exempt under Sec
B.&P.C, for this reason
Date
Date:
Signature
❑ Exemption for Reg, Moint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and fine
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permil is issued
(Sec. 3097, Civ. C.),
Lender's Name
Lender's Address
I certify that I have read this oplo kcation and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes.
Signature of Permittee Dore
FOR APPLICANT TO FILL IN
JOB
ADDRESS
New Residential Bldgs. & Pools
1 & 2 -Family, Sq. Fit
EACH
NO.
FEE
LOCALITY
$
—
$
Multi -family Sq. Fl.
Residentio! Swimming Pools
Outlets: Rec Light Sw.
First 20
Total No. Additional
Lighting Fixtures First 20
Additional
Total Na.
Fixed Appliances Not Over 1 HP
Range_ Heater_ D.W. —
Oven —Dryer _ W.M. —
Top FAU — W, H. —
Hood _ Fan _ Other_
Dis _ Room Air Cond.
P
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over 1 to 10 incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Panelboards
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 Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)—
NEAREST
CROSS ST.
OWNER OR
FIRM NAME
MAIL
ADDRESS
CITY Tel. No.
PLAN CHECK
APPLICANT
ADDRESS
CITY Tel. No.
PERMIT
APPLICANT
ADDRESS
CITY Tel. No.
LICENSE OR Class.
REG. NUMBER
DISTRICT NO.
PROCESSED BY
FINAL
DATE G/ VALIDATION
FINAL
BY
,
►
PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
(Sub -Total)
SEE REVERSE FOR EXPLANATORY LANGUAGE