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HomeMy Public PortalAbout4849 ARDEN DR_Electrical__ WORKERS' COMPENSATION DECLARATION '76A6676A663 9DPW 3 87 APPLICATION FOR ELECTRICAL PERMIT O i hereby affirm that I have a certificate of consent To self CE-806G insu.e, -r a-certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF P B I W0 1.; or a certified cols the (Sec. 3800, Lab. C.) Policy No. ; [Company � FOR APPLICANT TO FILL IN JOB ❑Certified is hereby furnished. r EACH NO. FEE ADDRESS (/ copy Y ��-�J New Residential Bldgs. & Pools � �j $ _ $ - LOCALITY Lv Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft,��_ �T tion department. / GiI Multi-family Sq. Ft. CROSSNEAREST. �- J! � �� fT Residential Swimming Pools Date Applicant v /AIL OWNER OR FIRM NAM . -c CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESvt � jai>L -r1 First 20 (This section need not be completed if the work involved by Total No. Additional CITY o/ Tel. N2.,:;? the permit is for one hundred dollars ($100)or less.) that in the performance of the work for which this PLAN CHECK I certify P APPLICANT permit 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 APPLICATION G Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS �- with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY f Tel. No.fd.91 7111'— . ICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. REG. NUMBER L 7 Class. t` I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3'of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY a and Professions Code,and my license is in full force and effect. x d Size &Type HP, KW, KVA, or KVAR ��/"�r� f� 3+/ �/ Q License Number Lic. Class Up to 1 Incl. FINAL U sr� ��/ � Over 1 to 10 Incl. DATE �zD VALIDATION Cc Contractor F'P� Date Over 10 to 50 Incl. 77 ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY Q W Over 100 11 B.&P.C. for this reason Services, Swbd., MCC& Panelboards Z Date: 0-200 Amp. Under 600 V oil — Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V _ Exemption for Reg. Maint. Elect. SINGLE FAMILY "'""" -~-�.••" HOME OWNER-BUILDER DECLARATION Temp.'Power Pole &Appurtenances 4 T 1` Sign with One Branch Circuit -1 ` I hereby affirm that I am exempt from the Contractor's License � ,�0 Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ; i HL ._a Professions Code): Conduits&Conductors ❑ I, as owner of the property, will d6 the work and the Misc. se A = '•ar structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— � »• •�(• Business and Professions Code). CONSTRUCTION LENDING AGENCY e ;.••; ;:_:,: I hereby affirm that there is a construction lending agency for 131'_8`-#s i3_`! se 1 . the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). - - PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE OZ(p Lender's Address I certify that I have read this application and state that the I TOTAL FEE 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-menti ed propE for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _/Q.0_"7 t Signature of Permittee Date ©S