HomeMy Public PortalAbout4935 ARDSLEY DR_Electrical__ e ; .WORKERS'COMPENSATION DECLARATION CE-06 10/81 APPLICATION
-TION FOR ELECTRICALS PERMIT
4 4! hereby affirm•that: have a.certifipate of consent to self insure,
or a•certificate of Worker' Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy4hereof(Sec.3800,Lab.C.)
Policy No. Company- ' - FOR APPLICANT TO FILL IN JOB '
�❑ Certified copy is hereby.furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESSG.
'Certified co 1& 2-Family, Sq.Ft. $ _ $ LOCALITY-�P�
copy is filed with the'county building inspection
NEAREST ,I t .�J �J
department. Multi-family Sq. Ft. CROSS ST. @� fteo- �`/ d '� .ice
Date Applicant Residential Swimming Pools OWNER OR
:FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' lo MAIL J�
Outlets:Rec 'Light Sw.
COMPENSATION INSURANCE ADDRESS
This section need not be com letedlif the work involved by the First 20
0 6
( P CITY.-rfy� I+� Tel.Not�t��•-
permit is for one hundred dollars($100)or less.) Total No. Additional -� HECK r�f.0
PLAN CHECK/k,
I certify that in the performance of the.work for which this permit APPLICANT C'�1' fGL�(}/ipcuc+r�aGL7�l.Y�
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 ADDRESS4g3r/�®•Hn'VG
Total No. Additional CITY`eW C,+ Tel.No ./�1ys
Date ,Applicant � "`��"0�� "" ��•'� -
NOTICE TO APPLICANT: If, after' making this. Certificate of Fixed Appliances Not Over. 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 4,q_;5
provisions or this permit shall be.deemed revoked. Top —•FAU:`- WH M"
LICENSED CONTRACTORS DECLARATION. Hood Fan Other_ CITY" /i C Tel.N
J hereby affirm.that I am licensed under provisions of Chapter 9LICENSE 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. DISTRICT NO. OCES ED BY
Power Apparatus&Large Appliances v ' t
Size&'Type HP,KW,KVA,or KVAR 0
License Number Lic.Class t.' Up to 1 Incl. -- FINAL, U
Over 1 to 10 Incl DATE �/ 1�?7
(/ VALIDATION
Contractor Date Over 10 to 50 Incl.
❑ FINAL
I am exempt under Sea Over 50 to•100 Inca
Over 100 a
B.&P.C. for'this reason ` Cn
Services,Swbd.,MCC&.Panelboa' Z
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
El Exemption
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-
Code):
Misc. Conduits& Conductors
I,as owner of the property,will do the work and•the structure
s not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
and Professions Code). &7 4 61:3
CONSTRUCTION LENDING AGENCY # o;0 0 0 0'
I hereby affirm that there is a construction lending agency for the. d o,o
performance.of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) o /, ( �+ •
Civ.C-).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Le der's Address
I c rtify that I have read this application and state that the above TOTAL FEE -. .
inf•rmation is re . I agree to comply with all County ordinances
a State la s u40punt
ical wiring, and hereby authorize
re sentativ henter upon the above-mentioned
p e ty for i s o
�^ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature.of Permittee Date