HomeMy Public PortalAbout9506 BOGUE ST_Electrical__ r, WORKERS' COMPENSATION DECLARATION CE- 10/81 APPLICATION FOR ELECTRICAL PERMIT
I,.�ereby'affirm that I have a certificate of consent to self insure, CE-806G �
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.)
Policy NO. Company FOR APPLICANT.TO FILL IN JOB e7S�/ �Q� ^J.�.T C�
Certified copy is hereby furnished. New Residential Bldgs.&Pools
EACH, NO. FEE ADDRESS fp j 6���j 7
$ _ $ LOCALITY & Ce Certified
Certified copy is filed with the county building inspection 1 & 2 Family,Sq.Ft.
department. Multi-family Sq.Ft.' NEAREST
CROSS ST. fJ(i
Date Applicant Residential Swimming Pools OWNER OR y
FIRM NAME
Outlets:CERTIFICATE OF EXEMPTION FROM WORKERS' r /c-
Rec— Light — Sw. MAIL (�
COMPENSATION INSURANCE � 'Z('7 ADDRESS G
This section need not be com leted if the work involved b the First 20 !n
( p y Total No. Additional CITY Tel. _ U
permit is for one hundred dollars($100) or less.)
I certify that in the performance of the work for which thi permit APPLICANT CHECKPLAN
is issued, I shall not employ any perso any manners as to
become s bjec to the Workers'Comp tion Laws. Lighting Fixtures First 20 ADDRESS �.
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT y
NOTIC TO APPLICANT: If, after making this Certificate fQ�
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS •O• 0 Q
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ , 1
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other—, LICENSE
ther CITY (J��
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROC SE BY
/} r a
ry' /, Size& Type HP,KW,KVA,or.KVAR �' v ` e U
License Number v� 7 Lic.Class y
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE �_ VALIDATION 0
Contractor ZZ Over 10 to 50 Incl. U
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C.for this reason Over 100
N
Services,Swbd.,MCC& Panelboards /per Z
Date: 0- 200 Amp.Under 600 V v
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit J4
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 ;•- ,�
Code): '
:.in:•:
❑ Misc.Conduits & Conductors
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ~
Poo. _e
and Professions Code). €I`r' 5�_-
- b _
7'• f
CONSTRUCTION LENDING AGENCY E� •'17114J�
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) A-9
.J_
Civ.C.).
PLAN CHECKING FEELender's NamePERMIT ISSUING FEEa ;Lender's Address I I certify that I have read this application and state that the above TOTAL FEE
informati is correct. I agree to comply with all County ordinances
and laws regulating Electrical wiring, and hereby authorize
repre a lives of this County t enter upon the above-mentioned
pro r r inspection purpo SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ure of Permittee ate