HomeMy Public PortalAbout10214 DAINES DR_Electrical__ ` WORKERS'COMPENSATION DECLARATION• 76A663 10/81
I hereby affirm that I have a certificate of consent to self insure, CE-806G APPLICATION FOR ELECTRICAL PERMIT ;
or a certificate of Workers' Compensation Insurance, or a certified' COUNTY OF LOS ANGELES BUILDING AND SAFETY
` copy thereof(Sec 3800,lab C) y -
f 'Policy No - Company , FOR APPLICANT TO FILL IN -` -i JOB,,-
I! ❑ EACH NO _FEE ADDRESS'•'
Certrfied copy,is hereby furnished New Residential Bldgs & Pools
® 1 & 2-Family,Sq Ft $ _ $ LOCALITY G
Certified•copy is filed with the county budding inspection NEAREST
department Multi-family Sq Ft CROSS ST
Residential Swimming Pools IOwNER OR J
Date Applicant '` y.
y ti '';H '•y ''FIRM NAME _
b^ CERTIFICATE OF"EXEMPTION FROM WORKERS' Outlets Rec� Light �Sw" � `+'}- ": �� ~ MAIL
COMPENSATION INSURANCE' .` ADDRESS'. 10-7— r LFA.,
First 20r`.' ;"
.(This section need not be completed If the work involved by.the p 3 � ,t,�, CITY Tel No
permit Is for one hundred dollars($100)or less) Total,No Additional – + G
I certify that in the performance of the work for-+which this permit PLAN CHECK
. a APPLICANT
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'. _
Additional
Total No CITY'" - Tel No
Date Applicant Fixed Appliances Not'Over 1 HP,' PERMIT, j�
NOTICE TO APPLICANT If, after making this Certificate of APPLICANT !J Z'
Exemption,you should become subject to,the Workers Compensation Range_.Heater_ DW _
` provisions of the Labor Code,you must forthwith comply with such Oven Dryer,_YW M ADDRESS
provisions b�this permit be'deemed revoked Top .— FAU _,W H � � ��
•i - CITY .. -Tel No
LICENSED CONTRACTORS DECLARATION' Hood Fan — Other_
I hereby'affirm that I amlicensed unde pro'visioris of•Ctiapter 9 Dis Room Air Cond LICENSE OR Class
(commencinw
g dh'Section 7000)•of Division'3 of the Business and, p REG NUMBER -_I'd'3'
Professions Code,and my license is Iri full force and effectpower Apparatus& Large Appliances DISTRICT NN PROCE ED,BY
Type t2S i
f Size & T e HP,KW,KVA,or KVAR
License Number f f O 3- Lic'Class ' Up,to 1 Incl FINAL Ur
s /�/T�� �_ o� Over 1 to 10 Incl DATE VALIDATION_
Contractors - Date 2Over'10 to 50'Incl r IN V
❑ ' I am exempt under Sec _Over 50 to 100 Inc B W ._
Over 100• d
B&PC for this reason N
Services, Swbd,MCC & Panelboards Z
Date 0- 200 Amp Under 600 V
Signature 201 ,--1000-Arnp Under 600 V s
.❑ Over 1000 Amp or Over 600 V '
Exemption for Reg Mamt Elect
SINGLE FAMILY Temp Power Pole,& Appurtenances
HOME OWNER-BUILDER DECLARATION• Sign - i' One Branch Circuit - -
I hereby affirm that I am exempt from the Contractor's License-Law AXT.t
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits �, 4
Code) /• '27.t
❑ Mlsc'-Conduits& Conductors• t Il,cl1L+ a
I,as owner of the property,will do the work and the structure �CC111ha�
Is not,intended or offered for sale (Section 7044, Business Other(See Complete,Fee Schedule) '
and Professions Code) TOTAL. �-}�
CONSTRUCTION LENDING AGENCY k DECK 27.��r
I hereby affirm that there Is a construction lending agency for the
performance of the work for which this permit Is Issued(Sec 3097,'• PERMIT FEE (Sub'-Total), '
Civ C)
PLAN CHECKING FEE • y i
Lender's Name COCO-W/ 1 5/24/89
PERMIT ISSUING FEE ; • (� AM 9=01-
Lender's Address 349�tp�0
I certify that I have read this application and state that the above TOTAL FEE i ,
Information is correct I agree to comply,with all County ordinances
and State laws regulating Electrical wirinupg, nd hereby authorize
representatives of'this County to enter the above-mentioned
ses '
property for in purpo � - - - ,
_SEE REVERSE FOR EXPLANATORY LANGUAGE• _
Signature of arm Date �_