HomeMy Public PortalAbout9072 ACASO DR_Electrical_12/17/1980_fixtures and outlets WORKERS'COMPENSATION DECLARATION CE 806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate of consent to self COUNTY OF LOS AGELES BUILDING AND SAFETY
insure, or a ;.ertificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab. C.)
FOR APPLICANT TO FIL IN
Volic No. Company
New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY —
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST ;� •,
department. Residential Swimming Pools OWNER OR �y� ) f,
Date A licant // FIRM NAME / '•_ ,
pp Outlets: Rec.l2Light First
S OC ADDRESS e� ^� _
CERTIFICATE OF EXEMPTION FROM WORKERS' /,2— First io /
Total No. AdditionalCITY` _ Tel No. �/��
COMPENSATION INSURANCE r a
PLAN CHECK
(This section need not be completed if the work involved , �v APPLICANT 0
by the permit is for one hundred dollars Fixtures First 20
s ($100) or less.) ADDRESS
Additional �
Total No.—&2 p
I certify that in the. performance of the work for which this CITY T o.
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner PERMIT W
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. _ APPLICANTCZ d
Oven Dryer_W.M._ ADDRESS In
Date Applicant Top: FAU _W.H..
Hood _ Fan _Other_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond,�/ S0 S 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. PROCES D BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP, KW, KVA,or KVAR O
Up to 1 Incl.
" FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE / _�;� VALIDATION
Over 10 to 50 Incl. C
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL q
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 Fa
effect. Services
0-200 Amp. Under 600 V
License Number Lic.Class 201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole& Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): 0.2 8�, 2 A
Misc.Conduits&Conductors
I, as owner of the property, will 'do the work and the Other (See Complete Fee Schedule)— G
structure is not intended or.offered for sale (Section # o o o o o 2
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2;0 0 2 1,0 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) / o o o 21. 0 0 c=i
issued (Sec. 3097,Civ.C.). /
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0, 3 1 -80
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE 2 l
above information is correct. I agree to comply with all County v,
ordinances and State laws regulating Electrical wiring, and
herebyauthorize representatives of this County to enter upon
th above- ehtioned proper y.�forgg�ecfion purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee �_ Date