HomeMy Public PortalAbout10656 ARROWOOD ST_Electrical_4/26/1985_outlet a
WORKERS'COMPENSATION DECLARATION 76-663
�,,�•-. a -.� CE-806G(2-80) iPPUCAV FOR .
OC ELEC?�sCAS PS NT
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.)
Policy No. ' 4omy
panFOR APPLICANT TO FILL EACHNO. FEE
IN JOB
ADDRESS L
New Residential Bldgs.&Pools h
_[]_Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY E� C
Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection GROSS ST.
Residential Swimming Pools
department. � OWNER OR i
([ , � CU/ L�— // FIRM NAME
Date�kACpplicant /� /u�t Outlets: Rec.—Light Sw. MAIL
First 20 ADDRESS 065 1'r clod
CERTIFICATE OFEXEMPTION,FROM WORKERS' Total No. Additional CITY �t` Tel No.
COMPENSATION INSURANCE
PLAN CHECK 0
(This section need not be completed if the work involved PPLICANT. ' G U
Lighting Fixtures First 20 ADDRESS
by the permit is for one hundred dollars ($100) or less.) Additional
I certify that in the performance of the work foi• which this Fixed Appliances— Not Over 1 HP CIT m /v Tef No.�`�j`—lzl O
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 6 G tL
Oven Dryer_W.M. ADDRESS to
L z .
Date Applicant. Top FAU _W.H.._ GC /
Hood Fan —Other- CITI-n E Tel No. of
NOTICE TO APPLICANT: If,'after making this Certificate of Disp'. Room Air Cond.— LICENSE OR Gp _a
Exemption' •you should become subject. to. the Workers' REG. NUMBER Q p Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSE BY
.with comply with such provisions or this permit shall beTHPKWKVKVAR l ]
deemed revoked. Size&. ype , , A,or 16
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION VALID ION
Over 10 to 50 Incl:
FINAL/
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. B�
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100
ness and Professions.Code, and my license.is in full force and.
effect. Services 219-3.2 p
2 0-200 Amp. Under 600 V $� 0.0'0 0 0
License er��Lic.�C,la�ss �^'!_ O 201,-1.000 Amp.Under 600 V o 0
Over 1000 Am r Over 600 o
0 0.
V 0 ` 8 8 .
Contractor t✓4 at Y- p'o. 0 4 2 6=.8 5
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm ,that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
Misc.Conduits&Conductors
1, as owner of the property, will do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
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 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 y V
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