HomeMy Public PortalAbout6012 ENCINITA AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 ID/BI APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE806G
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 No. Compony FOR APPLICANT TO FILL IN JOB / ,tel
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS /Q0 �C
❑ Certified copy is filed with the county building inspec- I & 2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — `NEAREST /Q unQ s,
Residential Swimming Pools CROSS ST. f
Date Applicant OFIRWNER OR t
M NAME eQ
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight_Sw._ 'MAIL r /
COMPENSATION INSURANCE ADDRESS CY
s section neenot be completed if the work involved b First 20
(Thitid P Y Total Na Additional - CITY ^ 71Q Tel.
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this APPLICANT
PLAK
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. Additional
me-rs Ede!-'r/T /CITY 7e1. No.
Date '7 App /''licant Fixed Appliances Not Over 1 HP PERMIT // r
NOTICE TO APPLICANT: If, atter making this Certificate of APPLICANT /-,e,,_
toW
Exemption, you should become subject 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. CITY Tel. No. Q[
deemed revoked. Hood _ Fan' _ Other— J 7Q 7 '� /�'� l
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disc. Room Air Card. REG. NUMBER Q 9 e, Class. (�
(commencing with Section 7000) of Division 3 of the Business (STRICT NO. PR SSED BY
and Professions Code, and m license is in full force and,effect. 916
Power Apparatus 8 Large Appliances >_
p / Size & Type HP, KW, KVA, or KVAR' r. �� O
License Number 40! /0 Lia Class C Q Up to 1 Ind. FINAL V
/ / n _G Over 1 to 70 Incl. DATE �/ _Z tY
Contractors-E'2. /c ICI-Il tDate ���6 /l j Z3 VALIDATION O
Over 10 to 50 Incl. FINAL /� L~j
❑ I am exempt under Sec. Over 50 to 100 Inc BY _ 1 �"� a
B.&P.C. for this reason Over 100 v W
Date; Services, Swbd., MCC&'Panelboards D
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V -
❑ `
Exemption for Reg. Mainz, Elect, Over 1000 Amp, or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances
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 . 2'b 1 O 2 A
Law for the following reason (Section 7031.5, Business and
Professions Code): '
❑ Misc. Conduits &.Conductors
I, as owner of the property, .will do the work and the
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)
7044, Business and Professions Code). D . 1'0b
CONSTRUCTION LENDING AGENCY ,I , 1 :8-8 3
8
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, Cl,. C.),
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Leader'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
t e ab e-mentioned prop rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
!a t S F3
ignature o ermiRee Date t