HomeMy Public PortalAbout10144, 10128 BOGUE ST_Electrical_6/25/1991 WORKERS'COMPENSATION DECLARATION 71A019oFw9 e7 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to'self CE-806G
insure, ora c?rtificgte of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a'certifIed copy thereof (Sec. 3800, Lab C )
Policy Ko Company FOR APPLICANT TO FILL IN JOB `( h
F]Certified copy is hereby furnished New Residential Bldgs. 8 Pools EACH NO. FEE I
ADDRESS 1
❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft $ — $ LOCALITY
tion department Multi-family Sq. Ft NEAREST f�
Residential Swimming Pools CROSS ST uZeN
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.— MAIL r
COMPENSATION INSURANCE ADDRESS SIO/ C
(This section need not be completed if the work involved byTotal No. Additional First 20 CITY T.I. No �%�/`��
the permit is for one hundred dollars ($100)or less.)• PLAN CHECK +
I certify that in the performance of the work for which this Lighting Fixtures First 20 ADDRESS APPLICANT CSA,
permit is issued, I shall not employ any person in any manner
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so as to become subject to the Workers'Compensation Laws � ` �
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�- : ^ ' Additional
t Total No. CITY C Tel. No.
Date Z� Applicant '^^ Fixed Appliances Not Over 1 HP PERMIT
-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
with comply with such provisions or this permit shall be Top — FAU —W.H —
deemed revoked Hood — Fan —Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR-
- 1 ` l i
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG NUMBER "C -i Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY a
and Professions Code, and my license is�nfiu ll force4nd effect. Size &Type HP; KW, KVA, or KVAR O
4License Number ` 4 - c. Class J—� Up to 1 Incl. FINAL
C r _�� _ DATE
J l�\S� �Z Over 1 to 10 Incl. d-Z Z-� VALIDATION O
Contractor Date Over 10 to 50 Incl. FINAL U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY LU
B.&P.C. for this reason Over 100 d
ate: Services, Swbd., MCC& Panelboards ► Z
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
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Ft'
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits C? _ i
Professions Code): --
Ell, as owner of the property, will do the work and the Misc. Conduits&Conductors = I f� �•
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , -••E�li-• 4 a
) _ ® =
Business and Professions Code).
CONSTRUCTION LENDING AGENCY :-E��*•Y `�•�'''°'k
I hereby affirm that there is a construction lending agency for
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the performance of the work for which this permit-is issued PERMIT FEE (Sub-Total) 2(='`
(Sec. 3097, Civ. C.).
Lender's Name
PLAN CHECKING FEE
� /� E`!13 II,�-:j;it:� c;;i__t;' �•
PERMIT ISSUING FEE
Lender's Address TOTAL FEE 7�•�•,, i Ari u L
I certify that I have read this application and state that the `
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 '
Qe above-m�onSEE REVERSE FOR EXPLANATORY LANGUAGE
(as
gnature of Permittee Date