HomeMy Public PortalAbout6649 CLOVERLY AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 /p�no no 0n �2(� n o0 2(0�(�/� 1 7
I hereby affirm that.l have a certificate of consent to self CE-806G 1�11�I�U `v-/rV��OO H if 09 ,EL�ECUII� CALF .l!"LSIJ�IIVIIU T 1/3/ 71
insure, or a certifica4l0
F'WCrlcers' Compensation Insurance, COUNTY,OF LOS ANGELES BUILDIN ND 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 ��-
❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY E GJ/' �j�►
tion department.. Multi-family Sq. Ft. —'NEAREST
CROSS ST. r.4 Iggy'.ij el
Date Applicant Residential Swimming Pools OWNER OR y�
FIRM NAM5_7AIJi9
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets: Rec�Light Sw. ADDRESS-3d��1 rsti d��d�Y' tS Z,r Ao, ,
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by Total No. Additional CITY �tr� Tel. No.
the permit is for one hundred dollars ($100)or less.)
I certifythat in the of the work for which this PLAN CHECK
e performance 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 2Q ADDRESS
/ Total No. Additional' CITY Tel. No.
Date �-/I' Applicant Fixed Appliances Not Over 1 HP_ PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT' r+` G�/�f• �n� q@.
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_ Cre.1 �� Tel: No.�
ITYJ _ to
LICENSED CONTRACTORS.DECLARATION 'LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. C p
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO;' �-. „r / PROC BY
and Professions Code,and m license is in full force and effect. Power Apparatus 8 Large Appliances UQy D_
+� q Size&Type HP, KW, KVA, or KVAR' c o
License Number ��/-3.2 Lic. Class ` 4 Up to 1 Incl FINAL U
gV`.1/4 �� Over 1 to 10 Incl. DATE VA (DATION 0
Contractor�R»g+� Date Over 10 to 50 Incl. FINAL V
❑ I am exempt under Sec. Over,50 to 100 Inc.. BY LU
B.&P.C. for this reason Over 100 N
Services, Swbd., MCC &Panelboards ` Z
Date: ''0 -200 Am.p. Under 600 V D
Signature •201 - 1000 Amp.'Under 600 V
❑ Over 1000 Amp. or Over 600 V 7 6 9 A
Exemption for Reg. Maint. Elect.
#,o;o 0 0,0 2
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit '0 - 27.75
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 o.0 0 2 77 5
Professions Code):
❑ I, as owner of the,property, will do the work and the Misc. Conduits&Conductors - O a.1 1 �8 7
structureis not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D
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 �V
PERMIT ISSUING FEE (�
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
the above-mentioned property for inspection purposes. .
��oo� SEE REVERSE.FOR EXPLANATORY LANGUAGE
0 A44"w- - 9-//- X
Signature of Permittee Date