HomeMy Public PortalAbout9609 BROADWAY_Electrical__ WORKERS' COMPENSATION DECLARATION `76-m,°DPW 38J APPLICATION FOR ELECTRICAL PERMIT O
-1'hereby affirm that I have a certificate of consent to self CEpB G
insure, or a -arlificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN 'OB
ElCertifiedcopy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. DDRESS
❑ O
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ FEE A$ — LOCALITY
tion department. Multi-family Sq. NEAREST
m CROSS ST. �' L.y
Date Applicant Residential Swimming Pools OWNER OR
���yy(( FIRM NAME G
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec/LLight�$w.-3— MAIL
COMPENSATION INSURANCE First 20 'i ADDRESS
(This section need not be completed if the work involved by Total No. P Additional CITY Tel. No.
the permit is for one hundred dollars ($100) or lets.)
1 certify that in the performance of the work for which this PLAN
A-APPNICA CHECK
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 �' Z ADDRESS
Total No. -3 Additional CITY Tel. No.
Date �L ` Applicant / '�� '1/`
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —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 LICENSE OR
Disp. — Room Air Cond. REG. NUMBER Class.
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED 8Y
and Professions Code, and my license is in full force and effect. , O
Size & Type HP, KW, KVA, or KVAR �
License Number Lic. Class Up to 1 Incl. FINAL �. U
Over 1 to 10 Ind. DATE ><y v` VA TION cc
Contractor Date Over 10 to 50 Incl. F-
I❑ am exempt under Sec. Over 50 to 100 Inc. Ed
B.&P.C. for this reason Over 100 d
Services, Swbd., MCC& Ponelboards Ln
Date: 0 5 9.0 A
0- 200 Amp, Under 600 V , z
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Moint. Elect. Over 1000 Amp, or Over 600 V
SINGLE FAMILY Tem Power Pole 8 Appurtenances
:1 - - 2550
HOME OWNER-BUILDER DECLARATION p' ppa e 2 5 5 0
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Q 9.0 2—Pi 8
Professions Code):
1, as owner of the property, will do the work and the Misc. Conduits &Conductors
'zt4s
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— ,
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 qs,PERMIT ISSUING FEE
Lender's AddressI 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 ab �ed lyfor inspection purposes.
G SEE REVERSE FOR EXPLANATORY LANGUAGE
$' nature o ermittee '� Date (R4