HomeMy Public PortalAbout9064 ACASO DR_Electrical_5/16/1983 WORKERS'COMPENSATION DECLARATION CE-806 10181 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES '-`� BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.) r
Policy No. Company FOR APPLICANT TO FILL IN JOB -
❑ Certified co is hereby furnished. ADDRESS
PY Y New Residential Bldgs. & Pools EACH NO. FEE �
❑ 1 & 2-Famil S Ft. $ — $ LOCALITY �l
Certified copy is filed with the county building inspec- Y, q
tion department. Multi-family Sq. Ft. NEARESTT.
Residential Swimming Pools CR OWNER OR /'
Date Applicant FIRM NAME ,4Q C-14-
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec-i—Light Sw._ AIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY -/Tel.
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 manner
so as to be ome sub the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. No.
'NOto Ap is in Fixed Appliances Not Over 1 HP PERMIT
TICE TO APPLICANT: If, after p ng this Certificate of APPLICANT
Exemption, you should become ject 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. — CITY Tel. No.
deemed revoked. Hood Fan —Other_
LICENSED CONTRACTORS DECLARATION `LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. — REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESS BY,
and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances _ //''
Size & Type HP, KW, KVA, or KVAR _7 AV O
License Number Lic. Class Up to 1 Incl. FINAL nQ U
Over 1 to 10 Incl DATE , ,� ,"`' VALIDATION 0
Over
Contractor Date 10 to 50 Incl �" �� ��".
FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. BYIM
B.&P.C. for this reason Over 100
Services, Swbd., MCC & Panelboards
Date: 0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑.
Exemption for Reg. Maint. Elect. K
Over 1000 Amp. or Over 600 V p 2 01.1 A
SINGLE FAMILY Temp. Power Pole & Appurtenances #'o o o opo 2
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 o 2 0.o 26.2 2 5
Law for the following reason (Section 7031.5, Business and
Professions Code): o 0 0 2 6,2 5 F
® I, as owner of the property, will do the work and the Misc. Conduits &Conductors
'
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ® 0S. 1 b—8 3
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 issued PERMIT FEE (Sub-Total)(Sec. 3097, Civ. C.).
0 �O tU n M PLAN CHECKING FEE
Lender's Name /IV (,ff e-�
��6: // 5V PERMIT ISSUING FEE
Lender's Address I�_
I certify that 1 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
hereb authorize representatives of this County to enter upon
thea ve-me tioned property for inspection purposes.
_ / SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date