HomeMy Public PortalAbout9027 ACASO DR_Electrical_6/18/1982_increase power amp WORKERS'COMPENSATIONDECLARATION CE806G (2=80) APPLICATION 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.) A
�l� /) /' ,/ \ FOR APPLICANT TO FILL IN ,JOB O� �
Policy No(dc':�= I Company�lr/L/C+ /IA/vIILLJJ ADDRESS E.
New Residential Bldgs.&Pools EACH NO. FEE
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — Is LOCALITY
Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST
Residential Swimming Pools
depa me t. OWNER M
FIRM NAME
Date Applicant Outlets: Rec.—Light— Sw. MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS'
Total No, Additional CITY Tel No. }
COMPENSATION INSURANCE. PLAN CHECK d
(This section need not be completed if the work involved APPLICANT O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS V
Total No. Additional
I certify that in the performance of the work for which thisCITY Tel No. 0
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner PERMIT
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT /7> W
Oven _ Dryer_W.M. ADDRESS fa
Top — FAU —W.H.. Z
Date Applicant CITY U Tel No. J
Hood _ Fah Other— '
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond-_ LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE D BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP, KW, KVA,or KVAR
Up to 1 Incl.
FINAL
Over 1 to 10 Incl. DATE'
LICENSED CONTRACTORS DECLARATION
Over 10 to 50 Incl. VALIDATION—"�"t
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL.
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY
ness and,Professions.Code, and my license is in full force and `•� d
effect.. r Services _ �+
License Nu �Lic.Class 0-200 Amp. Under 600 V eJ /
201-1000 Amp. Under 600 V
Contractor ate Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION
Temp. Power Pole&Appurtenances _
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
=
I, as owner of the property, will do the work and the Misc.Conduits&Conductors 4.4 2 3 A
Other (See Complete Fee Schedule)- '
structure is not intended or offered for sale (Section , # o 0 o o o 2
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY Z oto 2 3 5 0
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) 0 0 0 3 5
issued (Sec. 3097,Civ.C.). ,
Lender's Name
PLAN CHECKING FEE (One-Fourth Permit Fee). Q'6, 1 Fj'—$2
Lender's Address PERMIT ISSUING FEE
r
I certify that I have read this application and state that the TOTAL FEE 3
above information is correct. I agree to comply with all County '
ordinances and State laws regulating Electrical wiring, and
h y authorize representatives of this County t en er upon
ab e-me �dro erty for inspectintioon pur/ses SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Da e