HomeMy Public PortalAbout9174 JAYLEE DR_Electrical_8/23/1984_outlets,fixtures WORKERS'COMPENSATION DECLARATION '10/81
CE-806G APPUtAMN FOR ELECT � CAL, PERWr
I hereby affirm that I have a certificate of consent to self CE 806
insure, or a certificate of Workers: Compensation Insurance, COUNTY OF LOS ANGELES e BUILDING AND SAFETY
ora yrtif,�ed cop thereof (Sec. 3800, C.
P51icy No. 74ampany FOR APPLICANT TO FILL IN JOB
0 Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
1 &2-Family, S Ft. $ — $ LOCALITY
`{ Certified copy is filed with the county building inspec- Y 9• —
n department.
Multi-family Sq. Ft. NEAREST
-CROSS ST.
r2� Residential Swimming-Pools OWNER OR
Dote Applichn /a '
FIRM NAME /v
CERTIFICATE OF EXEMPTION FROM WORKERS' 7_ i MAIL g
Outlets: Rec Li hT Sw._
" COMPENSATION INSURANCE ) g � �� s ADDRESS c'
This section need not be completed if the work involved b First 20 �
/
the permit is for one hundred dollars ($100)'or less:) Additional
I certify that in the performance ofthewPLAN CHork for which this APPLICANT - ,
'permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional -.
Date Applicant CITY Tel. No.
Fixed Appliances Not Over l HP
NOTICE TO APPLICANT: If, 'after making this Certificate of PERMIT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. APPLICANT 40E� ,p� n Q
Compensation provisions of the Labor Code, you must forth- Oven Dryer W.M.— ADDRESS QCir J
with comply with such .provisions or This permit shall beTop FAU —W.H. —
deemed revoked., - CITY ��� Tel. No:
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
Dis SU LICENSE OR
I hereby affirm that I am licensed-under provisions of Chapter 9 P �— Room Air Cond. > REG. NUMBER
(commencing with Section.7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCE ED Bey'lv'
and Professions.Code,and my license is in full force and effect. �.
Size &Type HP,KW, KVA, or.KVAR' .mss I� O
License Number �"` ' Lic. Classes Up to 1 Incl. FINAL u
Over 1 to 10 Incl. DATE VALIDATIOP!
Contractor Date Over TO to 50 Incl. V
FINAL
1 am exempt under Sec. Over 50 to 100'Inc. BY LU
B.&P.C.Jor this reason Over 100 h
Services, Swbd., MCC& Ponelboards r D'
Date: 0 -200 Amp. Under 600 V CJ
Signature 201"- 1000 Amp."Under 600 V
❑ Over 1000 Amp. or Over 600 V v
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole &Appurtenances 3 7 5 2 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # o 0 o o o 2
1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and 1
.-Professions Code):.
❑ I, as owner of the property,.will do the work and the Misc. Conduits& Conductors .2.0'o (G t-5,10
structure is not intended or offered for sale (Section Other e Compe Fee-Schedule)—
7044, Business and Professions Code). D o Yo -- 4 1.5 0.6
CONSTRUCTION LENDING AGENCY 8`2.3_8 4 . -
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) j
(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
ordinances and State laws regulating Electrical wiring, and
here thorize re resentatives of this County to enter upon
the above ention pr perty pect'on purposes.
- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permute Date'