HomeMy Public PortalAbout4845 ARDEN DR_Electrical__ WORKERS'COMPENSATION DECLARATION -803 10/81 APPUCAMON FOR ELECTRICAL PERMIT
` I hereby affirm have
that I a certificate of consent to self insure, CE-608G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.-3800,Lab.C.) /y
Policy No. t + 7-Company FOR P FOR APPLICANT TO FILL IN JOB _
EACH. NO. FEE ADDRESS /
Certified copy is hereby furnished. / /d' New Residential Bldgs.& Pools �r
❑ 1 & 2-Family,Sq.Ft. rC`f�Q' . LOCALITY
Certified copy is filed with the county building inspection _ NEAREST
department:* Multi-family Sq.Ft. CROSS ST.
Date 1 (Applicant rLQ Residential Swimming Pools OWNER OR
// FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKjff�S' MAIL
COMPENSATION INSURANCE Outlets:Rec Light — Sw. 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 Tel.No.
I certifythat in the performance of the work-for which this permit PLAN CHECK
P P 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
Additional
Total No. CITY Tel.No.
Date -.Applicant Fixed Appliances Not Over 1 HP PERMIT -
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT.
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _
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.
CITY aIi✓ ., Tel.No. / 2•
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
1 hereby affirm that I am licensed under provisions of Chapter 9Disp. — Room Air Cond. LICENSE R
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER li Glass. -lo
Professions Code,and my license is,in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. �1 y P ED BY
�i aJ 0
Size& Type HP,KW,KVA,or KVAR 0
License.Number l.7 Lic. Class ":�Z- 6 Up to 1 Incl... FINAL 0
Over 1 to 10 Incl. DATE2U–q7– VALIDATION 0
Contractor–,a Date r Over 10 to 50 Incl
FINAL _ V
❑ I am exempt under S Over 50 to 100 lnc.. BY
B.&P.C.for this reason
Over 100 IL
Services,Swbd.,MCC&Panelboards
Date: 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 n
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'.
Code):• 'ff 165.`I .
rte•:
ElMisc.Conduits-& Conductors 1
f
I,as owner of'the property,will do the work and.the structure
is not intended or offered for sale (Section:7044, Business Other(See Complete Fee Schedule) _
...
and Professions Code). TO AL 16--_8 � 5
CONSTRUCTION LENDING AGENCY 16-uD 3
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) e i �.lf_ � fLt
Civ.C.).
PLAN CHECKING FEE
y^:
Lender's Name / % €jif0_€ _I 1
' PERMIT ISSUING FEE
r
Lender's Address Mi r=. _,
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
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitt Date