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HomeMy Public PortalAbout9026 ACASO DR_Electrical_8/31/1988_outlet �IO offir .ERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT I Vhereby affirm at .I have a certificate of consent to self ^'CE 8006E insure, or a fertiflCcF4, of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C. ( Policy No. Company FOR APPLICANT TO FILL IN (p 46, 19 �� ElCertifiedcopy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS /(!�/► ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. OWNER OR L� ��®B Date Applicant ^, � ^ FIRM NAME /�.•IC- CERTIFICATE OF EXEMPTION FROM WORKERS' OutIL lets: Rec Light Sw._ �i �� o9i/� COMPENSATION INSURANCE First 20 ADDRESS /71, , (This section need not be completed if the work involved by Total No. Additional CIT Tel./�/v Tel. 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 APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Date ®� � Additional Applicant ,/� � N ��� Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT. Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION 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: Y � 41410,Hood — Fan —Other_ CITTel. No. k�dp LICENSED CONTRACTORS DECLARATION Disp. — Room Air Cond. LICENSE OR � I hereby affirm that I am licensed under provisions of Chapter 9 Class. REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. �, PROCE SED BY >. and Professions Code,and my license is in full force and effect. /1 0- � 06� ��d Size &Type HP, KW, KVA, or KVAR �. v Q License Number Lic. Class U Up to 1 Incl. FINAL `��� Over 1 to 10 Incl. DATE/ -�% / j A (DATION Ir Contractor//U�L� �/��®.t-Date d� _ G' 0 F-1 Over 10 to 50 Incl. FINA I am exempt under Sec. Over 50 to 160 Inc. gY` U B.&P.C. for this reason Over 100 LUD_ Services, Swbd., MCC& Panelboards ) ' U) Date: L v Z 0-200 Amp. Under 600 V� rQ Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Mainz. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License � Q 5 b,3A Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): # o'oto.® 0 2 ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fe Schedule)_ , ( 0 - 26,2.5 � Business and Professions Code). f104l/A9' CONSTRUCTION LENDING AGENCY -4-'49AJ5 '0 0 - 262530: 1 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) 0&3'1 :-8 8 (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address 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 t S ordinanc St laws regulating Electrical wiring, and l/ hereb utho a repr sentatives of this County to enter upon thea e- enti ned prope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 2 /�r Ile; J V ©s ignature o Permittee Date "