HomeMy Public PortalAbout4947 ARDSLEY DR_Electrical__ WORKERS' COMPENSATION DECLARATION 7 10i81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806E-806 G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.E���%✓���'tompanyl/JG/f'OG ��J/7/ a FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furn shed. New Residential Bldgs. &Pools EACH PNO. FEE ADDRESS
(may 1 & 2-Family, S Ft. $ $ LOCALITYCertified copy is filed with the county building inspec- Y- 4tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re� LightSw.� AIL
COMPENSATION INSURANCE ADDRESS -::51 _-7_:2 5,1
First M
(This section need not be completed if the work involved by CITYTel. No.
the permit is for one hundred dollars ($100)or less.) Total No. Additional S, ii ,�+, _3 7 '-.S"S'4P
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 03 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 '�L' ✓� rri/�S�rli�
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 G - 17.- 14
with comply with such provisions or this permit shall be Top _ FAU ,W. CITY Tel. No.
H. — i
ddeemed revoked. ti
3
Hood _ Fan _Other— �
LICENSED CONTRACTORS DECLARATION LICENSE OR
.16
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER ' S Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances 0.
/� Size &Type HP, KW, KVA, or KVAR'
License Number 42 7 ef-kV Lic. Class .Z-3 Up to 1 Incl. FINAL -yam %d
im
Contractor �G ,f? /%�-5S��-Date � —� Over 1 to 10 Incl. _- DATE ."'�f� VALIDATION
❑ Over 10 to 50 Incl.. FINAL (�
I am exempt under Sec. Over 50 to 100 Inc. BY d-- LU
B.&P.C. for this reason Over 100
► v
Date: Services, Swbd., MCC& Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and G
Professions Code): y 2 6 Ik A
#
I,.as owner of the property, will do the work and the Misc. Conduits& Conductors
o 0 0 0 0 2
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ pool7044, Business and Professions Code). 2 -,o 4[L 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for o,o,o 4 4,506)
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 7. 1 1 -8 4
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
9nature of Permitteee