HomeMy Public PortalAbout10648 ARROWOOD ST_Electrical_12/13/1984_outlet, svc amp •�' WORKERS' COMPENSATION DECLARATION 76A663 10/81 o 0 0 0 0 0
4ereey affirm that I have,a certificate of consent to self CE-806G Lappd�CQ�DOO �] ��Q C �C ��Q�C�ad p�Q���
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob:C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.�e�LCompany FOR APPLICANT TO FILL-IN. JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
S _
Certified copy is filed with the county,building inspec- t & 2-Family, 4� Ft. $ $ LOCALITY
-7
tion department. Multi-family Sq. Ft. NEAREST
CROSS ST. •f''
,/ K- Residential Swimming Pools OWNER OR
Date1� 7Applicanl„� f74� FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets: Rec Light Sw._
COMPENSATION INSURANCE I
First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY t. �� 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
e P 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 IN Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANTTQ X C �_
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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 ' 3 7
with comply with such provisions or this permit shall be Top — FAU —W.H. — p�
deemed revoked. CIT Tel. Nlm
LICENSED CONTRACTORS DECLARATION Hood Fan _Other_
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 BusinessDISTRICT NO. PROCESS D BY
Y
and Professions Code, and m! � license is in full force and effect. Power Apparatus.& Large Appliances
-7 Size &Type HP, KW, KVA, or KVAR' �r��
License Number ffa fl Lic. Class Up to 1 Incl FINAL V
Contract or!{'/1�d4d �ti�illPte 1c�-1i Over Ito 10 In/cl. DATE rC� VALIDATI 0
❑ �—T— - / Over 10 to 50 Incl. FINAL c� U
CJ
I am exempt under Sec. Over 50 to 1.00 Inc. BY 14 LU
B.&P.C. for this reason Over 100'
Services, Swbd., MCC& Ponelboards
Date: 0 -200 Amp. Under 600'V U
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. 12 2 1 A
SINGLE FAMILY Temp. Power Pole &,Appurtenances T.,0 o
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o 0 0 26255
I 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 12 3 8/�'
Professions Code):
❑ I, as owner of the:property, will do the work,and the Misc. Conduits.&Conductors'
structure is not intended or offered for sale (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) S
(Sec. 3097, Civ. C.).
PLAN CHECKING,FEE
Lender's Name
PERMIT ISSUING FEE U S
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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
. I ,