HomeMy Public PortalAbout4841 ARDEN DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPUCATIOM FOR ELECTRICAL PERMIT
CE-806G
-I'hereby affirm that I have a.certificater ofconsent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
-copy therdof(Sec.•3800,Lab.C.)
Policy No. Company - - FOR APPLICANT TO FILL IN JOB 7
ADDRESS 4'� v,
Certified copy is hereby furnished. //9� New Residential Bldgs.& Pools EACH NO. FEE
❑ 1 & 2'-Family, Sq.Ft._/ _ $ — $ LOCALITY
Certified copy is filed with the county building inspection
department. Multi-family Sq.Ft. NEAREST
g Pools Oi
i
Residential Swimming CROSS
Date R
. 1�pplicant�� �� � OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION,FROM WORK Outlets: RecLight _ Sw. MAIL
COMPENSATION INSURANCE ADDRESS
.(This section need not be completed if the work involved by the First 20
Total No. Additional CITY Tel.No;
permit is for one hundred dollars ($100) or less.) '
I"certify that.in the performance of the work for which this permit PLAN CHECKAPPLICANT
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
NOTICE TO APPLICANT: If, -after making this Certificate of Fixed Appliances Not Over 1 HP 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 l
provisions or this permit shall be deemed revoked. Top FAU W.H.
LICENSED CONTRACTORS DECLARATION CITY
Hood Fan Other_ Tel.No.
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og
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR—
(c
R _ Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER ce
Professions Codd,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PRO E ED BY
Q
t— Size & Type HP,KW,KVA,or KVAR
License Number /�J L� Lic.Class e/---ZQ Up to 1 Incl. FINAL U
{�P7� �j - Over 1 to 10 Incl. DATE `li_ IX
4 i l/ `7 VALIDATION
Cdntractor� � /J�J' Date � � Over 10 to 50 Incl. O
Q FINAL
❑ I am exempt under Sec. y //� Over 50 to 100 Inc. gy W
B.&P.C.for this reason Over 100 G_
Services, Swbd.,MCC& Panelboards Z
Date: 0- 200 Amp.Under 600 V �^
Signature 201 - 1000 Amp. Under 600 V
ElExemption
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
I hereby affirm that I am exempt from the Contractor's License Law -
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Vii; i q
Code): r"7 t
❑ `'`" k _
I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors '
1
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). 11110. "-A 165 .
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)
Civ. C.).
PLAN CHECKING FEE '
Lender's Name ;!(>,D0 i F10 0 'j 7�
PERMIT ISSUING FEE
Lender's AddressAll ri z
50
I certify that I have read this application and state that the above TOTAL FEE f �i
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 inspectiort purpose
� 9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 4 ate '