HomeMy Public PortalAbout4868 ARDSLEY DR_Electrical__ WORKERS'COMPENSATION cafe of corse CE-896 10/81 ; APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consertt to self i CE-896G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES _r, BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.) r
Policy No. Company FOR APPLICANT TO FILL IN JOB /
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS t Z
❑ 1 & 2-Famil S Ft. $ _ $ LOCALIT
Certified copy is filed with the county building inspec- Y. q�
tion department. Multi-family Sq. Ft. 'NEAREST
Residential Swimming Pools CROSS ST.
Applicant OWNER OR
Date A
pp FIRM NAM�_ffi
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Recl—Light E W. MAIL
COMPENSATION INSURANCE First 20 r ADDRESS
�
(This section need not be completed if the work involved by Total No. Additional CITY el. No.
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'n any manner
so as to become subject to the War ers'Comp nsation Laws. Lighting Fixtures First 20 .t ADDRESS
I
� Total No. Additional
L �I�E CITY Tel. No.
Date//Y-- Applica t Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of Range— Heater D.W. APPLICANT
Exemption, you should become subject to the Workers' 9
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 Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class. `
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES Y
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances J� CL
Size &Type HP, KW, KVA, or KVAR' !� O
License Number Lic. Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE o�J � VALIDATION o
Contractor Date Over 10 to 50 Incl. G�
FINAL U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY LU
B.&P.C. for this reason Over 100 of
Services, Swbd. MCC& Panelboards , Z
Date: p00 Amp. Under 600 V 1 3,7
A.
Signature 201 - 1 mp. Under 600 V o n o 0 v2
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. 5 0
SINGLE FAMILY Temp. Power Pole & Appurtenances ,
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit Q
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits ( 1 i C1__L,
LF:W)fsions
'the following reason (Section 7031.5, Business and —
Code):as owner of the property, will do the work and the Misc. Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Com tete F Schedule)_ ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 3-
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name C O
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that.the TOTAL FEE �3 5
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby autho 'ze representatives of this County to enter upon
4the -men 'oned property for inspection purposes.� ' —Z� �(/� SEE REVERSE FOR EXPLANATORY LANGUAGE
of Permittee / Date `�