HomeMy Public PortalAbout9021 EMPEROR AVE_Electrical__ WORKERS COMPENSATION DECLARATION f CE-8066 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that i have a certificate of consent to self CE-806
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 NoSU9g5q Company S"TA77t 1_
000 FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs 8 PoolsV EACH NO FEE ADDRESS
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft $ — $ LOCALITY �� C'
tion department Multi-family Sq Ft —t NEAREST
n
Residential Swimming Pools CROSS ST fl� ►�r ttia
Date tL Applicant OWNER OR
FIRM NAME Cb lv (p1,i
CERTIFICATE`OF EXEMPTION FROM'WORKERS' Outlets Rec Light Sw_ MAIL '7 S6 I £ ST
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No Additional CITY C)lL,3 1, Tel No Z ,QC(J
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
permit is issued, I shall not employ any person in any manner F
so as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20 ADDRESS
Date
' Applicant Total No Additional
Fixed Appliances Not Over 1 HP PERMIT
CITY Tel No
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�r'
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO l PROCESSED BY >_
and Professions Code, and my license is in full force and effect �/�j D A.
Size 8 Type HP, KW, KVA, or KVAR �j 0
License Number Lic Class Up to 1 InclV
FINAL
Over 1 to 10 Incl DATE �d•/ -;> oe
Contractor Date l VALIDATION
Over 10 to 50 Incl V
FINAL
❑ I am exempt under Sec Over 50 to 100 Inc BY _ r an,e,. W
B&P C for`this reason Over 100 h
Date
Services, Swbd , MCC& Ponelboards ► Z
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 r �bign
5Zith
er Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION
ne rant ircui
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
Professions Code)
1, as owner of the property,'will do the work and the Misc Conduits& Conductors A144 �-4 Q ie� .. P �e—
structure is not intended or'offered for sale (Section Other (See Complete Fee Schedule)_ ► A
7044, Business and Professions Code) !
CONSTRUCTION LENDING AGENCY -
'25887A
I hereby affirm that there is a construction lending agency for #Io o jo 0 0 2
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) �� J _ J_.;
(Sec 3097, Civ C ) -
I PLAN CHECKING FEE - - 2,o,-,25,,50
y
Lender's Name 0 0 0 2 5 5 0
PERMIT ISSUING FEE F
Lender's Address Q1 1 —83
I certify that I have read this application and state that the TOTAL FEE y
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
thea ove ntioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
is
gnoture of Permittee bate