HomeMy Public PortalAbout10144, 10128 BOGUE ST_Electrical_6/23/1988 r t WORKERS' COMPENSATION DECLARATION 2o-aotvDPW 3ie7 APPLICATION FOR ELECTRICAL PERMIT
,? . f;*Thereby affirm that I have`o certificate of consent to self CEe663
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a,cert fieri-copy thereof (Sec 3800, Lab. C )
n r
Policy No,��f ",�Company(> or 0-1,
lns1, FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished New Residential Bldgs. & Pools EACH NO FEE ADDRESS C1
❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department Multi-family Sq Ft — NEARESTCROSS ST
/
Residential Swimming Pools OWNER uR /
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rez Light/`- Sw.9 MAIL / 7�
COMPENSATION INSURANCE tS
ADDRESS L• 1 ��%t
(This section need not be completed if the work involved byTotal No. AddiFirst tionalft CITY
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this !, APPLICANT
permit is issued, I shall not employ any person in any mannerLighting Fixtures 16 First,20 Z U ADDRESS
so as to become subject to the Workers'Compensation Laws.
/ Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT 2 r
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
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 sj6� s
with comply ,with such provisions or this permit shall be Top — FAU —W.H. — /
deemed revoked. Hood — Fan —Other— CITY C�1/r Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR G
Disp.' — Room Air Cond. — - REG. NUMBER 3 p Zee '�- Class C�U
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. u / PROCESS d
and Professions Code,and my license is in full force and effect. /J�{ O
Size &Type HP, KW, KVA, or KVAR ✓✓✓«<+++
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License Number Q � ��.� .� Lic. Class C -�b Up to 1 Incl. FINAL r Q
r .3.;a^ —` Over 1 to 10 Incl. DATE/ 2 ��C� VALID ION 0
Contractor�1 o /Pr v� pate' U
❑ Over 10 to 50 Incl. FI -
I am exempt under Sec. Over 50 to 100 Inc LU
U Q
B.&P.C. for this reason Over 100 CL
Services, Swbd., MC�.100P ards
Date Z
0-200 Amp. Un "
Signatur 20 - 1 mp.
❑ Exempt for Reg. Maint. Elect. Over 1000 Amp or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION 9 9 8.,0;A
Sign with One Branch Circuit F
I hereby affirm that I am exempt from the Contractor's License #;o•o o s,0 2
Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code). ) e;o 7600
Ell, as owner of the property, will do the work and the Misc Conduits&Conductors o -o a 7& 0'0:5
structure is not intended or offered for sale(Section,7044, Other (See Complete Fee Schedule)—
Business and Professions Code) o6 2 4 8
CONSTRUCTION LENDING AGENCY
I 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)
(Sec 3097, Civ C ) `
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE d
Lender's Address /
I certify that I have read this application and state that the TOTAL FEE 600O
above information is correct I agree to comply with all County
ordinances and State jaw regulating Electrical wiring, and
hereby authorize repres atives of this County to enter upon J
the ab e- enti d perty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si lure o P tee Date