HomeMy Public PortalAbout9962 BROADWAY_Electrical__ .a•�:FCOMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
. I-herely affirir that
CE 8m that I have a certificate of consent to self CE806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB G
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
❑ $ — $ LOCALITY
Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft.
tion department. Multi-family Sq. Ft. — 'NEARESTCROSS AN
Residential Swimming Pools OWNER OR �J
Date Applicant ✓//' 11,4110e S
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets: RecLighi_Sw._ ADDRESS J1N✓
( completed if the work involved b
This section need not be com First 20
Y
the permit is for one hundred dollars ($I00)or less.) Total No. Additional CITY Tel. No. 0-1"51j 4OC
certify that in the performance of the work for which this PLAN CHECKAPPLICANT
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 ADDRESS
Total No. Additional
CITY Tel, No.
Date Applicant Fixed Appliances Not Over 1 HPPERMIT //
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT x'rc.'i/�' 1%?-f-/IVC S
Exemption, you should become subject to the Workers' Range. Heater—D.W. —
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. — 1 Qr/
deemed revoked. Hood Fan _ Other_ CITY' ���. t ` �� Tel.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG, NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCESSED >,
and Professions Code,and my license is in full force and effect Y y
Size 8 Type HP, KW, KVA, or KVAR O O
License Number Lic. Class Up to I Incl. FINAL V
Over I to 10 Incl. DATE VAUDATIO 0
Contractor Date❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY 1 w
B.BP.C. for this reason Over 100 L 17 9 A CL
Z
Dote: Services, Swbd., MCC 8 Ponelboords # o o ° ° e 2
0 - 200 Amp. Under 600 V ir
Signature 201 - 1000 Amp. Under 600 V I ° - 2550
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V 00025505
SINGLE FAMILY Temp. Power Pole 8 Appurtenances 0403-85
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
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
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
Other (See Complete Fee Schedule)—
structure is not intended or offered for sole (Section ,
7044, 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 'L
PERMIT ISSUING FEE U
Lender's Address Q
I 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 above-mentioned r perry far inspection purppses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date