HomeMy Public PortalAbout5755 CLOVERLY AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby, affirm that 1 ,have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY Iu'
or a certified copy tth9ereof (Sec. 3800, Lab. C.)
Pl cy No. Z ( Company r"' FOR APPLICANT TO FILL IN JOB t� ,� ,I
-33
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS �� J �-Q a 2.�C
❑o
1 & 2-Family, S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspec- Y. q —
tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools OWNER OR
Date ( y Applican CROSS S
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��JJ FIRM NAME b CCYY1�AfJ
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�� Light 9 Sw.! MAIL
COMPENSATION INSURANCE ADDRESS
Thi
tid t bcompleted if the work involved b First 20
( s section neenoe cam p y Total No. Additional CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) . PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
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.Z Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT 113
�y
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT 04L.
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. yS'G711-
LICENSED CONTRACTORS DECLARATION LICENSE OR
hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER 3 Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances O
Size & Type HP, KW, KVA, or KVAR' CJ
License Number2IL Y3 Lic. Class Up to 1 Incl. FINAL 411
�� .l—; r? Over 1 to 10 Incl DATE 2 VALI ION O
Contractor '1 Dare Over 10 to 50 Incl. 1,1
❑ FINAL L>1
I am exempt under Sec. Over 50 to 100 Inc. BY j p„
Over 100
B.&P.C. for this reason ► / Z
Date .7�'" Services, Swbd., MCC & Panelboards
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.
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0 0.2
1 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 0 0 5625
Professions Code):
F-1 1, as owner of the property, will do the work and the Misc. Conduits & Conductors 0 o,0 5 6,2 55
structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ ►
7044, Business and Professions Code). 0 2.24-87
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
PERMIT ISSUING FEE
Lender's Address �
I certify that I have read this application and state that the TOTAL FEE L
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 a coned p rty .inspection purposes.
j� R SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit e Date d