HomeMy Public PortalAbout9548BISBY ST_Electrical (4)i
WORKERS'COMPENSATION DECLARATION 7&6.663 10/01 APPLICATION FOR ELECTRICAL PERMIT
I hereby afflrm thatS
I have a certificate of consent to self CE '
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 PON AF?LICANT TO FLU IN 108
Certified copy is hereby furnished. New Residential Brdgs. 8 Pools EACH 1,40' FEE
Certified copy Is filed with the county building Inspec- 1 &2-Family, Sq. Ft. $ — $ LOCAI�ITY
tion department. Multi-family Sq. Ft.� — NEAREST
Residential Swlthming Pools �5
Ddte App(ICant FIRMRM NAME Letr /
(CERTIFICATE OF EXEMPTION FROM WORKERS` Outlets: Rec Light Sw._ L
COMPENSATION INSURANCE Alm
(This section rss,.d not bo'completed If the work l volvod by First CITY Tet. No.
the permit h for one hundred dgllors (:100)or less,) Total No Additional /
PLAN CHECK
I certify that In the performance of the work for which this , CANT
pgrmit It Issutid, l shall hot employ any Perron In any manner
to as to become subject to the Workers Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Addltldnal CITY Tel. No.
Date licanT r 4, Fixed Appliances Not Over 1 HP PST r
NOTICE TO CANT; If, after making Kit Certificate of A?PL1CANf �•
Exemptron, yoo should become subject to th'e' Workers' Range_ Heater_D.W.
Compensation provlslons of the Labor Code, you must forth- Oven _ Dryer —W,M.— ADOIZESSZk
with comply with such provisions or this permit shall be TooFAU —W.H.
deemed revoked. Hood _ Fan _Other— CITY Tel. No.
LICENSED-CONTRACTORS DECLARATION Dlsp. Room A1r Cdnd. REG. NUMBER *9 Claes. C,7
I hereby affirm that I am licensed under provlslons of Chapter 9
(corprrmhcing with Section-7000) of Division 3 of the Baslneu DISTRICT NO. P BY
and Professions Code,and m license Is In full force and effect. Power Apparatus 8 Large Appliances
, Size d Type HP, KW, KVA, or KVAR . o U
�oa'b�
License Number_ _I Fp. C1. C_/0 to 1 Incl. FI AV,
/ f r Over 1 to 10 Incl.' DA ~� VALIDATION 0
Cohtractor /`��+ ^J G/dG late3-2-241- Over 10 To 50 Incl. O
FINAL
I am exempt under Sec. Over 50 to 100 lac. BY rf a• .r ��� ssLL
B.BP.C_ for this reason Over lOQ V s
dq Date: 3 $ervia", Swbd„ MCC&Ponelboards �. z
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600'V
❑ fiver 1OQ0 Amp. or Over 600 V
Exemption for Reg. MOIat, Elect.
SINGLE FAMILY Iemp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION $Ign with One Branch Clrcult -_9'0'6 5 3'A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Sectlort 7031.5, Buslneu and Additional Sign Branch Circuits
Professloos,Code): 0 0 2.
�{
Misc. Conduits$Conductors 2'F Jr
u t,�as owner of the property, will do the work and the
structore Is not Intended or offered for saie (Section Other (Sbe Complete Feq SchddvIe)_ 1 i
7044, Buslness and Professions Code). , o o•q 2 a v D Tu
CQNSTRUCTION LENDING AGENCY 3 2 2'-•83
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued PEkMIT FEE (Sub-Total)
(Sec. 3097, CIv. C.
PLAN CHECKING FEE 1.
Lender's Name
PERMIT ISSUING FEE
Lender's Addreu
I certify that I have read this application anq state that the TOTAL FEE ISO
above Information Is correct. I agree to comply'with all County
ordinances qnd State laws regulating Electrical wiring, and
h by authorize representatives of this County to enter upon
a o-mentloned property for Irspection purpdses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ermittee Dafe
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