HomeMy Public PortalAbout9560 BISBY ST_Electrical__ WORKERS'CI have 4TIQlflcot liof consent
7eA� 10/81 APPLICATION FOR ELECTRICAL PERMIT
til.heroby"afflrm that I have a certificate of consent to self CE-806G �(
Insure, or a certificate of Workers' Compensation Infurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY FIJI
or a certified opy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO Hl IN gppRF55 6 0 !S
Certified copy is hereby furnished. New Residential Bldgs. & Is EACH I'0' FEE
f — f LOCALITY
® Certified copy If filed with the county building Inspec- 1 8 2-Family, Sq. t. NEAREST
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tion partm t. Affi"WMulti-family Sq. F. — CR06S� �- /�J
Residential Swimming Pools J
Date Applicant OR w,4 Ao
FIRM OWNERt U1AtiE
R IFICATE OF EXEMPTION FROM KERS' �'p�-+� Outlets: Rec�Llpht L
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COMPENSATION INSURANCE (� First 20 V n � 11./z
(This section need not be completed N the work InvoFeed by Total No_ qlo Additional CITY Te js
the permit Is for one hundred dollars (:100)or Isrss.) AP15txANT
% �-4 --IF-
I certify that In the performance of the work for which this
permlt Is Issued, I shall not employ any person In any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 2D
DDRESS
Total No._ Additional �In el. No Cr
Date- Ar,Ilcant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of
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Exemption, you should become subject to the Workers' Range_ Heater Jf D.W. — APPIJCANT d
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer L 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 Dlsp. Room Air Cond. LICENSE OFF Clue.
I hereby affirm that I am licensed under provisions of Chapter 9 B•
(commencing with Section 7000) of Dlvlslon 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. _ BY
and Professions Code,and my license Is In full force and effect.
Size &Type HP, KW, KVA, or KVAR ✓r l/
License Num 11 C_ Class Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE — V }O
DATN
Contract Date Over 10 to 50 Incl.
FINAL
I am exempt under Sec Over 50 to 100 Inc. BY
Over 100 U)
B.BP.C. for this reason Z
Date: Services, Swbd., MCC& Ponelboards Pilo,200 Amp. Under60D 249&8A
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V #,o o o o o 2 '
Exemption for Reg. Malnt. Elect. ) o
SINGLE FAMILY Temp. Power Pole &Appurtenances o 49.25
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 0 0 0 4 9.2 5 6
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 Q 7 0 9 a 8 6
Professions Code):
I, as owner of the property, will do the work and the Mlsc. Conduits&Conductors
structure Is not Intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Professlons 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
Lendees Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
above Informatlon Is correct. I agree to comply with all County
ordinances and Slate laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the abo a property for Inspectlo purposes.
/ SEE RF1/FRSE FOR EXPLANATORY LANGUAGE
Signature o er es ��� Date