HomeMy Public PortalAbout4826 BALDWIN AVE_Electrical__ (2) • WORKERS' COMPENSATION DECLARATION -80 10/81
CE-80
6G APPLICATION�ICATIO FOR ELECTRICAL PERMIT
I hereby affirm that I have^a certificate of consent to self insure,
or a certificate of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO,FILL IN JOB rjy//
❑ 'Certified copy is herebyfurnished. EACH NO. FEE ADDRESS DO,/, zZ.
New Residential Bldgs.& Pools _
❑ Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ — $ LOCALI -
department. Multi-family Sq. Ft. — NEAREST
CROSS
Residential Swimming Pools OWNER 0 y
Date Applicant OR
FIRM NAM vZ
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light Sw. ::ti .MAIL y
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY T�!Z/�� Tel.No.rj/ G�_ Zjs.
I certify that in the performance of the work for which this permit PLAN CHECK
' APPLICANT
is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU _ W.H.
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ CITY Tel.No.
I. hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. P O SSED BY }
Size & Type HP,KW,KVA,or KVAR ��
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 incl. DATE Jz j /� w
Contractor Date i 7 VALIDATION 0
Over 10 to 50 Incl. FINAL ~
❑ I am exempt under Sec. Over 50 to 100 Inc. BY U
W
BAP.C.for this reason Over 100 N
Date:
Services,Swbd.,MCC& Panelboards , Z
0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 4
1 hereby affirm that I am exempt from the Contractor's License Law r•,• Z
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits i+_.t =r
Code): --
-k.. ..`r
P/0 I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors � r7'
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
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 permit is issued(Sec.3097, PERMIT FEE (Sub Total) a t_. !;N ,10C
`
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE j1
Lender's AddressI r'7 y rl� :; x `L
1 certify that I have read this application and state that the above TOTAL FEE
v
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
/�ri�rty for inspection purposes. �( SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatures Permittee Date /