HomeMy Public PortalAbout9034 JAYLEE DR_Electrical_5/29/1985_outlets,light fixtures WORKERS'COMPENSATION DECLARATION CE-806 10,81 . APPUCQTDON FOP, ELECT ° U CAL pC�U3t1vM�U�
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.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is.hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS p�
❑ 1 & 2-Fomil S Ft. $ _ $ LOCALITY
Certified copy is filed with the county building inspec- Y, q
tion department. Multi-family Sq. Ft. NEAREST f-
Ss r t CROSS ST. .�sz.:_Ql['=
Date. 1 Applic Residential Swimming Poo OWNER OR AA
—O� FIRM NAME LCGA.j' • t�(�¢`
CERTIFICATE OF EXEMPTION FROM RKERS" � MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw.
ADDRESS
First 20
(This section need not be completed if the work involved by Total No. Additional CITY . 1 Tel. No.
the permit is for one hundred dollars ($100)or less.)
I certifythat in the performance of the work for which this PLAN CHECK•
p APPLICANT
permit is issued, I shall not employ-an y
mploy any person in any manner _
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY el. No.
Dcit�^ v Appy ',��, - s
ixed Appliances of Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after makirAvki,7c,ertificate of APPLICANT
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. Na
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. PROCESSED BY
and Professions Code,and my
license is in full force and effect. Power Apparatus& Large Appliances //)' 0.
0.
Size &Type HP, KW, KVA, or KVAR' ^ O
License,Number. Lic. Class Up to 1 Incl. FINAL V
Over 1 to 10 Incl. DATE ��G C�—' VALIDA OPd o
Over to Incl.Contractor Date O 10 50 I
_ FINAL 0
❑ I am exempt under Sec. Over 50 to 100 Inc. BY &.
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC& Ponelboards' D —
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V' 2 1 2 4 A
ElExemption
1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # 0 0 0.0 o 2
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION P 0 0 3 2 O O
Sign with One Branch Circuit
1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law Law for the following reason (Section 7031.5, Business and o 0 0 3 2 Q Q x
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits& Conductors Q 529-85
structure is'not intended or offered for sole (Section Other (See Complete Fee Schedule)_ D
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.).
PLAN CHECKING FEE,
Lender's Name
PERMIT ISSUING FEE 0
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
'ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-ment pned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature rmittee Date