HomeMy Public PortalAbout10714 ARROWOOD ST_Electrical_7/8/1980_light outlets, switches WORKERS'COMPENSATION DECLARATION
• 76A663,
CE-806G (2-801 iPnLAT10N FOR ELECTRICAL
PERMIT
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.)
FOR APPLICANT TO FILL IN JOB
Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
a Certified copy is hereby furnished. 1&2-Family,Sq. Ft. $ $ LOCALITY, _
❑ Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST � ( y
department. Residential Swimming Pools OWNER OR
FIRM NAME
Date Applicant � � MAIL
Outlets: Rec.--Light--L First
i ADDRESS
First 20
CERTIFICATE•OF EXEMPTION FROM WORKERS' , Total No. s—• Additional CITY I Tel No. >
COMPENSATION.INSURANCE PLAN CHECK d
APPLICANT O
(This section need'not be completed if the work involved Lighting Fixtures First 20 V
by the per is for one hundred dollars (5100) or less.) ADDRESS
Additional cr
Total,No. / . .. O
I certify that in the performance of the work'for which this Fixed Appliances Not Over 1 HP _ U
permit is issued, I shall not employ atiy person in any manner PERMIT'CITYTel No.
soas to become subject'to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT pw.
% L z
Oven Dryer_W.M._ ADDRESS'
Date ApplicantcG M Top FAU W.H.
/ r Hood Fan _Other_ / CITY Tel No.
,NOTICE TO APPLICANT: If, after making this Certificate ofDisp. _ Room Air Cond,_ / LICENSE OR
Exemption; you should become subject to the 'Workers' REG. NUMBER class
Compensation
Compensation provisions of the Labor Code, you must.forth- Power Apparatus& Large Appliances DISTRICT NO. PROC SSED BY
with comply' with such provisions or this permit shall bet !
Size&Type HP,KW, KVA,or KVAR
deemed revoked.
Up to 1 Incl.
FINAL. .
Over 1 to 10 Incl.. DATE VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to•50 Incl'. f cis` Q
I hereby affirm that,I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
BY
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 �-
ness and Professions.Code,'and my license is in full force and
effect. -
Services
12,License Number L ( i Class
_0-200 Amp. Under 600.V �
201-1000 Amp. Under 600 V /
Contractor I ate Over 1000 Amp.or Over 600 V ! `
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5; Busi- -Additional Sign Branch Circuits.
ness and Professions Code):,
Misc.Conduits&Conductors
a.I, as owner of the property, will do the work and the Other (See Complete Fee Schedule) ;2 ..I A
structure is not intended or offered fur sale (Section
7044, Business and Professions Code). # 0,0 0 0 0.2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency, 2 0 - 2850
for the'performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.)., o o'o y
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 2�'J`0
Lender's Address PERMIT ISSUING FEE •0 7 O.g 8.Q
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 proper y for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Oate