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HomeMy Public PortalAbout10684 ARROWOOD ST_Electrical_4/10/1991_light outlets and switch WORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 • herAPPLICATION FOR ELECTRICAL PERMIT O . her---by affirm tht'I hcertificate f y aave a cercate oconsent to self . CE-806G v..nsureCE-806, Qr a ceoificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS a;.a ciAtifLet copy thereof(Sec. 3800, Lab. C.) Policy.No.- Company FOR APPLICANT TO FILL IN JOB ❑ l0 40/j �^�^`Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS / �J ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY CI tion department. Multi-family Sq. Ft. — NEAREST Q Residential Swimming Pools CROSS ST. Date Applicant OWNER OR a CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: FIRM NAME Rec�Light Sw, MAIL y p COMPENSATION INSURANCE First ADDRESS {c (This section need not be completed if the work involved b 1.1— First 20 I y Total No. Additional CITY -e:)." C'f T.I. No. the permit is for one hundred dollars (=100)or less.) PLAN CFIECK I certify that in the performance of the work 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 1 ADDRESS Additional Date Applicant f_ Total No. CITY Tel. No. t?t NOTICE TO APPLIC NT: If, after making this Certificate o Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION �� J 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 Tel. No. LICENSED CONTRACTORS DECLARATION 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 Business Power Apparatus & Large Appliances DISTRICT NO.�./ PR SSED BY >_ and Professions Code,and my license is in full force and effect. t1 Size &Type HP, KW, KVA, or KVAR Pf U License Number Lic. ClassU Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATE n i VALIDATION 0 Over 10 to 50 Incl. FINAL / F- I am exempt under Sec. Over 50 to 100 Inc. BY {/�. W B.&P.C. for this reason Over 100 t1 Services, Swbd., MCC& Ponelboards Z Date: 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole & Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit - ;*: ya Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): -3,0t` i I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors _ j j ;I structure is not intended or offered for saleSection 7044, Other(See Complete Fee Schedule)_ a �- .- :jp o Business and Professions Code). ( , TOIF a0-0 CONSTRUCTION LENDING AGENCY =_`HECK 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) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name Ili l(€ice-€_l ,i 1 W PERMIT ISSUING FEE �3 d 7` 4_ Lender's Address iS"1 i fil•, o_I 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 la Signature of Permittee Date ©s