HomeMy Public PortalAbout9537 BLACKLEY ST_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT {�
I hereby affirm that I have cer ificate of consent to self insure, CE-806G d-i L1
or a certificate of Workers' Corm-i-stion Insurance, or a certified COUNTY OF..LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
PolicyNo. y FOR APPLICANT TO FILL IN JOB / ) J y
❑ Certified copy is herebomuprrnshed. EACH NO. FEE ADDRESS V� 7 8 4 G 1-,_4e 3-C
New Residential Bldgs.&Pools
❑ Certified co 1 & 2-Family, Sq.Ft. $ — $ LOCALITY
py is filed with the county building inspection
department. Multi-family Sq.Ft. NEAREST I
CROSS ST. �i OV%,
Date Applicant Residential Swimming Pools OWNER OR � I
FIRM NAME 4�G W A� /4
1r'''(`
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL /
COMPENSATION INSURANCE Outlets:Rec— Light Sw. ADDRESS 3 ? �R k S
(This section need not be completed if the work involved by the First 20
permit-is for one hundred dollars ($100)or less.)
Total No. Additional CITY(� �`L Tel.No.a�—C f 51,/
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not .employ any, person in,any manner so as to ' APPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU _ W.H. _
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE
DISp. Room Air Cond. REG.NUMBER
ER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO. PR ESSED BY
Power Apparatus& Large Appliances.
Size& Type HP, KW,KVA,or KVAR 0
U
License Number Lia Class Up to 1 Incl. FINAL /
Over 1 to 10 Incl. DATE VALIDATION Q
Contractor Date Over 10 to 50 Incl. FINAL U
❑ I am exempt under Sec. Over 50 to 100 Inc. BYAr W
B.&P.C.for this reason Over 100 • N
S es,Sw MCC & Panelboards ® Z
Date: 2 0 Amp Under 600 V
Signature 01 - 1 Amp.Under 600 V
❑ .Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power.Pole:& Appurtenances aCGT°v
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits fie` b
Code): 05.° 0
XI,as owner of the property,will do the work and the structure Misc. Conduits & Conductors 1 ITEMS
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). I�
CONSTRUCTION LENDING AGENCY TOTAL 165 m 60
I hereby affirm that there is a construction lending agency for the 16 1
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Q
Civ.C.).' Ln
PLAN CHECKING FEE �
°
Lenders Name
PERMIT ISSUING FEE O�
Lender's Address nnnn tNt
I certify that I have read this application and state that the above TOTAL FEE �Q S 60 0000-0001 9/20/95
information is correct. I agree to comply with all County ordinances q�t
and State laws regulating Electrical wiring, and hereby authorize 2307 1 F17111�OQ'
representatives of this County to enter upon the above-mentioned
Wfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatureof ermitte, Date