HomeMy Public PortalAbout9174 JAYLEE DR_Electrical_8/28/1984_power apparatus 76A66
WORKERS'COMPENSATION DECLARATION CE 806E (2-80) A11'il'Lb CA ll �ON FOR LS IC U II ICAL IT CSll NII
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.)
FOR APPLICANT TO'FILL IN- JOB ry
Policy No. CompanyADDRESS
New Residential Bldgs.&Pools EACH NO. FEE
Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY 'r
❑ Certified co is.filed with the count building Multi-family Sq; Ft: — NEAREST
copy y g inspection CROSS ST
department. Residential Swimming Pools OWNER OR ti
FIRM NAME
Date Applicant Outlets: Rec._Light_Sw. MAIL G?
First 20 ADDRESSA LAI,
CERTIFICATE OF EXEMPTION,FROM WORKERS' Total No. Additional CITT I No.
COMPENSATION INSURANCE }
PLAN CHEC t1
APPLICAN
(This section need not be completed if the work,involved T 0
DRESS
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 AD
Additional cc
Total No. O
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY,' Tel No.' U
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. APPLICANT t1
Oven Dryer_W.M. ADDRESS Cn
Z
Dat ? 8 Applian Z Top _ FAU _W,H.,—
Hood Fan _-Other_ CITY Tel No.
NOTICE TO APPLICANT: I fter making th s Certificate of Disp. Room Air Cond._ LICENSE OR
Exemption, you should become subject t the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCEESSED BY
with comply with such .provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR r � /
deemed revoked. U 4,15 f
Up to 1 Incl.
. FINAL
Over t010IncL DATE �^
LICENSED CONTRACTORS DECLARATION VA IDATION
Over 10 to 50 Incl.
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.Cod e, and my license is in full force and
effect. Services .
' License Number - Lic.Class 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or,Over 600 V. r
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances o
3Sign with One Branch Circuit g 3
I hereby, affirm that I am exempt from the Contractor's Additional Sign Branch Circuits '}f•o 0 0 0,'0 2
License Law for the following reason (Section 7031.5, Busi-
ness and Professions,Code): ' :o 7. 5
Misc.Conduits&Conductors
❑ I, as owner of the property, will do the work(Section
the Other (See Complete Fee Schedule)— ' .
structure is not intended or offered for sale Section o oo
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0 ,S 2 8=8 4
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) .�
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE' (One-Fourth Permit.Fee)
Lender's Address PERMIT ISSUING FEE
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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i —
ignature of Per tee Ilate '