HomeMy Public PortalAbout4815 CLOVERLY AVE_Electrical__ WORKERS COMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affvCE 8m th4t I have a certificate of consent to self. CE 806G
rtdure or a,cdrt,ficate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified'copy tliereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
� 11 / ,t
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS �'T���
Certified copy is filed with the county building inspec 1 & 2-Family Sq Ft $ — $ LOCALITY 7_bFm9d,E C 17--x/
tion department Multi-family Sq Ft — NEAREST � al✓�p
o Residential Swimming Pools CROSS OWNER T
Date Applicant ft
y� FIRM NAME
OR
CERTIFICATE OF EXEMPTION FROM WORKERS t2� !11* MAIL
COMPENSATION INSURANCE Outlets Rec Light Sw ' At L__ ADDRESS A✓�
r--First
(This t be completed ,'` 15-DS
( is section neenot if the work involved by Total No Additional . � RCITY����� �,Jj–�/ Tel No
the permit is for one hundred dollars ($100)or less )
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT .54419
permit is issued I shall not employ any person in any manner
so as to become subject to the W ers' om nsation Law Lighting Fixtures First 20 ADDRESS
Total No Additional
y CITY Tel No
Date Appl,ca Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If a ter making this Cert, ate of fi
APPLICANT 5/}A1
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
deemed revoked Hood _ Fan _ Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 D,sp _ Room Air Cond �� REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO ED BY Dom.
and Professions Code and my license,s,n full force and effect O
P
Size &Type HP KW KVA, or KVAR ✓r/C/ 7" V
License Number L,c Class Up to 1 Incl FINAL 6=
Over 1 to 10 Incl d DATE VALIDATION
Contractor Date Over 10 to 50 Incl
❑ FINAL W
I am exempt under Sec Over 50 to 100 Inc BY � V)B&P C for this reason Over 100 V)
Date Services, Swbd , MCC& Panelboards ► / / /��
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
Exemption for Reg Ma,nt Elect Over 1000 Amp or Over 600 V
SINGLE FAMILY Temp Power Pole &Appurtenances 00
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
rofess,ons Code)
M,sc Conduits&Conductors ;2 6 0 3t 6 A
I as owner of the property will do the work and the
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ y
7044 Business and Professions Code) , a 0 O
CONSTRUCTION LENDING AGENCY o a - 6 9 2 5 6
I hereby affirm that there ,s a construction lending agency for
the performance of the work for which this permit ,s issued PERMIT FEE (Sub-Total) 1 2 0 1 -1-86
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE l
Lender s Address
I certify that I have read this,application and state that the TOTAL FEE
above information ,s correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and
ere authorize representatives of this County to enter upon
he ab ve-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
1-� 441
Signature of PrerAittee 7 Date
11 'i
WORKERS COMPENSATION DECLARAilO�f ,' 76A66T joie' �) u
APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate'of consent to self CE-8066
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 \/ _
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
ADDRESS
b
El
LOCALITY — _
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft — �-
tion department Multi-family Sq Ft — NEAREST
cRoss ST 2(JSf,►
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME V
CERTIFICATE OF EXEMPTION FROM WORKERS' � t I MAIL
Outlets Rec LighT Sw I_
COMPENSATION INSURANCE 174' DRESS
This section need not be com leted if the work involved First 20
( p b Y Total No Additional CITY�„ Tel No� 06
the permit is for one hundred dollars ($100)or less )
OP
I certifythat in the performance of the work for which this PLAN HECK
�
permit is issued I shall not employ any person in any manner APPLICANT
o as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 S ADDRESS
) � � _ Additional
�„ Total No l CITY Tel No
Date ^_^ ppjicant �U/ �� 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 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 —
deemed revoked Hood Fan _Other_ CITY Tel No
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& Large Appliances DISTRICT NO PROCE D BY
and Professions Code and my license is in full force and effect
Size 8 Type HP, KW, KVA or KVAR 5 71
License Number Lic Class Up to 1 Incl FINAL V
Contractor Date Over 1 to 10 Incl DATE VALIDATION 0
❑ Over 10 to 50 Incl FINAL ~
j am exempt under Sec Over 50 to 100 Inc BY I W
B&P C for this reason Over 100 N
Services, Swbd , MCC & Panelboards ►
Date 0 - 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect I
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 2 1 5 2 3 A
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 # e o 0 0 0 2
Professions Code) ,
❑ j as owner of the property will do the work and the Misc Conduits&Conductors 2 0 1 2 7 5
structures not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► ;
7044 Business and Professions Code) +
� o - 1275
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 5125-84
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097, Civ_C ) fig- n _
S PLAN CHECKING FEE -
Lender s Name
PERMIT ISSUING FEE 0 �(
Lender s Address
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
Je ove-m ion property for inspection purposes
rr [[�� SEE REVERSE FOR EXPLANATORY LANGUAGE
to, J —1r -r7^`
Signature of Per ittee Date