HomeMy Public PortalAbout9635 LAS TUNAS DR_Electrical_6/6/1984_LIGHT OUTLETS WORKERS'COMPENSATION DECLARATION CE-806G, 10i81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES ` BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. �/ �
�` �l�4'Q Com ` FOR APPLICANT TO FILL IN JOB
Policy No pony 6 -3 ;-x-41 fA �1V14J jj�
54
Certified co is hereby furnished. EACH NO. FEE ADDRESS
777"`""""' copy Y New Residential Bldgs. & Pools
Certified copy is filed with the county building iinspecc-- 1 & 2-Family, Sq. Ft. $ = $ LOCALITY Lf- L/ T
tion department. /' �" T Multi-family Sq. Ft. NEAREST !'1I
7. Residential Swimming Pools OWNER OR
Date004 Applicant �d /-
� ' FIRM NAME
CE TIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecyLi ht Sw._ MAIL J n
COMPENSATION INSURANCE g First 20 " S ADDRESS 3 S LAS %�4S .0
(This section need not be completed if the work involved by Total No. Z1_ Additional CITY +,y L t ela Tel. No.
the permit is for one hundred dollars($100)or less.)
PLA
I certify that in the performance of the work for which this A PLICANTK
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
I Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT /Gmr w Z-3 e "1
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, Z
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood Fan _Other— CITY�� ���`� Tel. No.
LICENSED CONTRACTORS DECLARATIONLICENSE 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 DISTRICT NO. PROCESS By
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances �/ d
(�lj L/ Size &Type HP, KW, KVA, or KVAR ��� a Q
License Number /6/ /` Lic Class_ U to 1 Incl. FINAL V
/ �l Over 1 to 10 Incl. DATE �•• .+' � ' VALIDATION 0
Contractors -''YY Date �s7 Over 10 to 50 Incl. / V
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY � ,4 �,.l.� U.
IL
Over 100
BAP.C. for this reason H
Date:
Services, Swbd., MCC & Ponelboards 00- ?
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&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 (Section 7031.5, Business and
Professions Code):
❑ Misc. Conduits 8 Conductors
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
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) 0
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE l v Sd
Lender's Address a, OCA
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 pr perry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee ate