HomeMy Public PortalAbout9635 LAS TUNAS DR_Electrical_6/6/1984_OUTLETS WORKERS' COMPENSATION DECLARATION CE-806 10/81 APP (�ATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-8066
insure, or a certificate of Workers' Compensation Insurance, COUNTY OS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy Nd! Company FOR AP 1CANT TO FILL IN 108
Certified copy is hereby furnished. New Residential Bldgs. & PooEACH NO. FEE
ADDRESS
l _ $ LOCALITY�1• �: - Y ;
ElCertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _
tion department. Multi-family Sq. Ft. NEAREST r z
CROSS ST.
Date lA licant "'f Y Residential Swimming Pool OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec w Light w. MAIL
COMPENSATION INSURANCE g ADDRESS
This section need not be completed if the work involved b Fir t 20
( P Y Total No. ✓ q itional CITY pj `-/✓ Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK'r
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 Fi t 20 ADDRESS
Total No. ditional CITY Tel. No.
Date Applicant Fixed Appliances Not Over HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT : "' w'✓r ! "f
Exemption, you should become subject to the Workers' Range_ Heater_D. —
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer W M.— ADDRESSwith comply with such provisions or this permit shall be �j
P Y P P Top FAU —W H. — CITYri ti w Y'rrr :,Tel. No.
deemed revoked. '
Hood _ Fan _Other_ -
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER s' I `- _ Class.;-
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY CL
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances O
..•�` p Size &Type HP, KW, KVA, or KVAR V
License Number Lic. Class =' Up to 1 Incl. FINAL J
W
�,.,�; f k, Over 1 to l0 Incl. DATE VALIDATION U.
Contractor,_' -a�' Date / Over 10 to 50 Incl.
FINAL >_
❑ <
I am exempt under Sec. Over 50 to 100 Inc. BY Q
Over 100 IM
B.&P.C. for this reason Q
Date: Services, Swbd., MCC& Ponelboards , a.
0 - 200 Amp. Under 600 V W
Signature 201 - 1000 Amp. Under 600 Vf-
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. �` � • • a •
SINGLE FAMILY Temp. Power Pole& Appurtenances e ♦ ; ? r)
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 • w • ' '� '
Law for the following reason (Section 7031.5, Business and
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)_ ,
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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT 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
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 ate'