HomeMy Public PortalAbout4918 BIRCHLAND PL_Electrical_1/6/1982_service amp ,
WORKERS'COMPENSATION DECLARATION 76A883
i CE-B06G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have ■ certificate of consent to self COUNTY OF LOS ANGELES, r]— C BUILDING AND SAFETY
Wawa, or a certificate of Workers'Compensation Iruurance,or
a certiflad copy thereof(Sec.3800,Lab.C.)
II 'fm pan S:! ryiy FOR APPLICANT TO FILL IN JOB
Policy N-#V22C
p New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
❑ Certified copy Is hereby furnished. 1 &2-Family,Sq. Ft. a — L LOCALITY
. M tl-femlly Sq. Ft.- NEAREST
rtlfied y h filed th co bu Identlel Swimming Pools CROSS ST
i dep me OWNEROR
FIRM NAME
Dat pllc lets: Rec..___Light Sw. MAIL
—first 20 ADDRESS !Yqler_ 00000
CERTIFI Total No. Additional CIT o.
COMPENSATION INSURANCE
PLAN CFFECK'
(This section ❑ not be completed if the work tamolved APPLICANT
Lighting Fixtures Flrrt 20
by the permit tl one hundred dollars (=100) or lora.) Addltionpl ADDRESS Cr
I certify that in the p ormanca of the work for which this Total No.� CITY aI No.
O •
i permit is issued, I shall ❑ employ any person in any manner Fixed Appliances Not Over 1 HP
PERMI
so as to become subJect to a Workers'Compensation Laws. Range_ Heater_D.W. APP CANT
Oven _ Dryer_W.M._ ADDREMq
"�
Date Applicant Top _ FAU _W.H.
Hood _ Fen Other_ CITY 81 No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond` R
Exemption, you should become subject to the Workers' REG.N MBER ass
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DIST ICT NO. PROCE ED BY
with comply with such provisions or this permit shill be
deemed revoked. Size&Type HP,KW, KVA,or KVA ��-•
Up to 1 Incl. J i0
Over 1 to 10 Incl. FINAL
VALIDATION
LICENSED CONTRACTORS DECLARATION
r Over 10 to 60 Incl.
I hereby affirm that I am Licensed under provisions of Chapter Over 60 to 100 Inc. FINAL
9 (commencing with Section 7000) of Dhrision 3 of the BwBY
i- T— Over 100
noes and Profmalona.Code, and my license L in full force and
effect. Services ~
Llgense Number�rC_5Lf41assael
a Amp. Under 600 V
��^^ _ ) J 201-1000 Amp. Under 600 V 9
Contno�li�/d/CJ �1 Over 1000 Amp.or Over 600 V Q
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenenc--as
Sign with One Branch Clrcuh
I hereby affirm that I em exempt from the Contractor's Additional Sign Branch Circuits
I Llcanse Law for the.following reason (Section 7031.5, Busl-
❑eas and Professions Code):
Misc.Conduits&Conductors
I, 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 2 Jr 4 O A
7044, Business and Professions Code).
• `CONSTRUCTION LENDING AGENCY'
I hereby Ifflrm that there Is a construction lending agency # o 0 0 o a 2
for the performance of the work for w ch this permit Is PERMIT FEE (Sub-Total) 2'00 1.Jr O
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
e e�'e 1 1,50
Lender's Address 44PERMIT ISSUING FEE 0 1,0 6=8 2
I certify that I have road this application and state that the TOTAL FEE O
shove ormation Is correct.I agree to comply with all County
n an State laws regulating Electrical wiring, and
h eby ut a repres a f t ter upon
e vo- tloned ❑ SEE'REVERSE FOR EXPLANATORY LANGUAGE
3lg1atuFe ofee to