HomeMy Public PortalAbout9548BISBY ST_Electrical (5) WORKERS'COMPENSATION DECLARATION � Jo/et APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self J
Insure, or a certificate of Workers Compensation Insurance, -COUNTY OF LOS ANGELES BUILDING AND SAFETY
ar a certified copy thereof (Sec. 3800, Lab.C.)
alcy No. Company FOR AlMLFCANT TU Rl IN JOB _577
-
Certlfied copy Is hereby fumished. New Residential Bldgs. 8 Pools EACYI NO. FEE
Certlfled copy Is filed with,the county building Inspec- 1 8 2-Famlly, Sq. Ft. _ = f LOCALITY
tlon department. Multi-family Sq. Ft. GROW E�.lZ!~5T
Residential Swimming Pools OWNER OR L
Date Applicant
FIRM NAME
CERTIFICATE OF DCEMPTION'FROM WORKERS' Outlets: Rec Llght Sw._ MAR
COMPENSATION INSURANCE
First 20
(This sectbn need not be completed If the work Involved by Total No Additional CfTY (f;7y Tel. No. `
tho permit u for one hundred dollars (=100)or less.) PLAN CHECK
I certify that In the'performancd of the work for which this APPLICANT
permit Is Issued, I shall not eA(an In any a erw as ro om ubjed to tasst Lighting Fixtures First 20 ADDRESS
Total No. Addltlooal CITY Tel. No.Date IlcFixed Appliances Not Over 1 HP PERMFr
NOTI .TO LI NT: If, Is Certificate of APPLICANT
Exemption, you should become sublett 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 C Tel. No.Z Q�/Lo
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 Dlsp. — Room Alr-Cond. � - Class.
(commencing with Section 7000) of Dlvlslon 3 of the Businam DISTRICT NO. BY
and Professions Code,and my license Is In full force and effect. Power Apparatus 8 Large Appliances d
? r/� Size 8 Type HP, KW, KVA, or KVAR' O
License Num ✓V 1Ic. Classes \ Up to 1 Incl. DATE
/
Over 1 to 10 Inc].to r 13 VALWATION O
Contractor Dote O10 50 Incl.
❑ FINAL rj
I am exempt under Sec. Over 50 to 100 Inc.. BY s+L+
B.BP.C. for this teason Over 100
Date: Services, Swed-, MCC 81wards ► 6'r /,7-40/,7-400 �200 Amp. Und600 Ver 600 V
Signature 201 - 1000 Amp. Under 600 V
EJOver 1000 Amp. or Over 600 V 1 !
Exemptioo for Reg. Malnt. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Sectlon 7031.5, Business and
Profession*Cc-do):
❑ f, as owner'of the property, will do the work'and the Misc. Conduits 8 Conductor
p ed Other (Sed Complete Fee Schedule)— I /I
structure Is not Intended or offered for saie (Section ► ,
7044, Business and Professions Codb}
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 PERMrr FEE (Sub-Total) 6�
(Sec. 3097, Clv. C.).
PLAN CHECKING FEE
Lender's Name
PERMR 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
ordlnan nd State laws regulating Electrical wiring, and
here a ze representat this County to enter upon
the an pr t Inspedlo pu SEE REVERSE FOR EXPLANATORY LANGUAGE
"9t ra Perm[ ee bote