HomeMy Public PortalAbout10656 ARROWOOD ST_Electrical_4/30/1985_outlets r .,WORKERS'fCOMPENSATIONDECLARATION CE806G (2-80) APIrUCATMUV FOR 'ELECTl('S CALF 1!"ISIf`SUC/11 Y
I hereby-affirm that I'have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.,3800,Lab:C.)
� aPt�` 1tb1]_ FOR APPLICANT TO FILL EACH N NO. FEE ADDRESS I l � A PROLO
' Policy No. pany
New Residential Bldgs.&Poo ls
❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft.' $ r $ LOCALITY
,{ Multi-family Sq. Ft. — NEAREST
11Xt'I Certified copy is filed with the county building inspection CROSS ST
Residential Swimming Pools
department. OWNER OR
• - FIRM NAME Ll S
Datz1ilJApplican rarr►id3y l dens Outlets: Rec.5 Light Sw. MAI L
First 20 .� ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS'. / y
Total No. Additional CIT -e Tel N �-
COMPENSATION INSURANCE . PLAN-TinnVI CHECK �-
( APPLICANT :5- o
(This section need not-be completed if the work involved U
by the permit is for. one hundred dollars ($100) or. less.) Lighting Fixtures First 20 ~
Additional
ADDRESS1 O cc
Total No. .3 Q
I certify that in the performance of the work forwhich this Fixed Appliances Not Over 1 HP CITY L Tel'No.Q
permit is issued, I shall..nbt employ any person in any manner PERMIT __P w� 1 ` d
so as to become subject to the Workers' Compensation Laws. Range_Heater_D.W. APPLICANT► as r�� L
Oven Dryer_W M._ ADDRESS, -r� Z
Date4'A Applicant Top F A U --WH.
—
Hood — Fan _Other— CITY Tel No.Q
0
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR
Exemption, you should 'become subject. to the Workers' REG.NUMBS Class
Compensation provisions of the Labor Code,= ou must forth- Power Apparatus,& Large Appliances DISTRICT NO. PROCESS D BY
with comply with such provisions or this permit shall be y( '
deemed revoked. Size&Type HP, KW, KVA,or KVAR (/ �
Up to 1 Incl.
FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION
Over 10 to 50 Incl: 7G(� VALI TION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to-100 Inc.
FIN
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100
By, �y, r,
ness and Professions.Code, and my license is in full force and .>/�l� °� : 1 9 5 2 A
effect. ,(������(�� -Q Services
License Number4_ 19t S!__l-- Lia Class 1" 0-200 Amp. Under 600 V #,'o•0 0 0 e2. .,
'J _ 201-1000 Amp.,Under 600 V
Contractor` X �� r� Over. Amp.or Over'600 V o o �`5
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances o o .9 2 0,5 0.0
I'hereby affirm that I_ am exempt from the Contractor's Sign with One Branch Circuit 3 5
License Law for the following reason (Section.7031.5, Busi- Additional Sign Branch Circuits Q 0—8
ness and,Professions Code):
Misc:Conduits&Conductors
,.as owner of proprty, will o the work and the El 1, f the eildhk h
Other (See Complete Fee Schedule)—
structure is not intended or offered .for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY'
I hereby:affirm that there is a construction lending agency
for the performance of the work for' which this permit is PERFEE (Sub-Total)
issued (Sec. 3097,Civ.C.). "
Lender's Name PLAN CHECKING FEE' . (One-Fourth Permit'Fee)
Lender's Address PERMIT ISSUING FEE
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
D.
` Signature of.Permittee Date