HomeMy Public PortalAbout8834 ELM AVE_Electrical__ 77�_Y,WORKERS,COMPEINISATION DECLARATION 10/81 APPUCAMN FOR ELEC�TMICad PERMT
" I hereby.affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY �
or a certified copy thereof (Sec. 3800, Lab. C.)
I
Policy No. Company FOR APPLICANT TO FILL IN JOB �p
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 25
1 8 2-Family, S Ft, $ — $ LOCALITY
Certified copy is filed with the county building inspec- y q•
tion department. Multi-family Sq. Ft. — NEAREST
CROSS ST.
Residential Swimming Pools �. ,
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL ((��
COMPENSATION INSURANCE ADDRESS L.GC �--
(This section need not be completed if the work involved by First 20Total No. Additional,i ti`�': ° �_ NCITY ( I Tel. No.
the permit is for one hundred dollars ($100)or less.) - r
I certifythat in the performance of the work for which this PLAN CHECK
P �
permit is issued, l shall not employ any person in any manner APPLICANT
so as to become subject to the Workers'_Qqmpensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. N/
Dated Applicant 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
Disp. _ Room Air Cond. Class.
I hereby affirm that I am licensed under provisions of Chapter 9 � REG. NUMBER
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO OCE ED BY 0-
Power Apparatus 8 Large Appliances ��
and Professions Code,and my license is in full force and effect. �� Q U
Size 8 Type HP, KW, KVA, or KVAR' U
License Number Lic. Class Up to 1 Incl. FINAL t ,
Over 1 to 10 Incl. DATE VALIDATION
Contractor Date Over 10 to 50 Incl. 0
❑ FIN W
I am exempt under Sec. Over 50 to 100 Inc. FI (-
/
8.8P.C. for this reason Over 100
�
Date: Servicies, Swbd., MCC 8 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 8 Appurtenances
AR
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
PP jfessions Code):
Jl� 1, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
✓✓ structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule.)-
7044, Business and Professions Code). —4 S 3&3 A
CONSTRUCTION LENDING AGENCY
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) V°:o 2 5 5.0
(Sec. 3097,Civ. C.).
PLAN CHECKING FEE oo 0 2 S 5 045)
Lender's Name 0 Q.9 8 i 8 6
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 urp ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
vSVlat� u�rmittee LYate