HomeMy Public PortalAbout6117 ENCINITA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663
Cr 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I ha�e a certificate of Consent to Self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'compensation insurance,or
a certified copy thereof(Sec. 3800, Lab. C.)
FOR APPLICANT TO F I LL I N JOB
Policy No.—Company New He identia I Bldgs &R. s EACH NO. FEE — ADDRESS 011,17 A 41e,
Certified copy'ishereby to I rnishied. 1 &2- a dy.Sq. Ft. $ $ — LOCALITY
Multi-famity Sq. Ft.— — NEAREST
Certified copy is filed with the county building inspection CROSSS7
department. Resid6ritial Swimming pools — OWNER C�R
F I R M N Alat�
Date— Applicant Outlets Re ht Sw. �5P6olMAIL
irs 4
L
't PO - IL ;ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. _7d_d_,tonaI __1_K_ CITY Tel No >
COMPENSATION INSURANCE PLAN CHECK tL
/,p �APPLICANT 0
(T6 section need not be completed if the work involved 0
by the permit is for one hundred dollars (SIOO) or less.) Lighting Fixtures FL
�4§1 20 ADDRESS
Total No.i�� Additional /��v cc
I certify that in the performance of the work for which this CITY Tel No. 0
Fixed Appliances Not Over I HP I—
permit is issued, I shall not employ any person in any manner PERMIT 0
so as to become subject to the Workers' Compensation Laws. Range Heater—D.W. — APPLICANT LU
a.
Oven — Dryer—W.M.— ADDRESS U)
Date—Applicant Top — FAD J_W.H. /. Z
Hood Fan —Other CITY
NOTICE TO APPLICANT: If, after making this Certificate of Dista. Room Air Card- 4�;v L-1 CE-N S E 0 R
Exemption, you should become subject to the Workers' REG.NUMBER CI.SS
Compensation provisions of the Labor Code, you must forth- Power Apparatus & Large Appliances DISTF31CT>JQ, 0
with comply with such provisio,ns or this permit shall be Size&Type HP, KW, KVA,or KVAR PR S 0 BY
Up to 1 Incl.
deemed revoked. 10
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Inc[. DATE VALIDATION
Over 10 to 50 1 ncl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the Busi. Over 100 BY
ness and Professions,Code, and my license is in full force and
effect. Services
% 0-200 Amp. Under 600 V
License Number— Lie. Class— 201-1000 Amp. Under 600 V
Contractor— [;are Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness arid Professions Code): ;2.,5.2 6 9'A
Misc.Conduits&Conductors
9/1, as owner of'the property, will do the work and the Other (See Complete Fee Schecl 0 2
structure, is not intended or offered for sale (Section
7044, Business and Professions Code). .2 -�5 0,0 0
CONSTRUCTION LENDING AOENCY
I hereby affirm that there is a construction lending agency 0, 0 015
for the performance.of the work for which this permit is PERMIT FEE (Sub-Totaf)
issued(Sec. 3097 C v C I
Lender s Name PLAN CHECKING FEE (One-Fourth Permit Fee))
Lender's Address PERMIT ISSUING FEE -;;7��Ve.
I certify that I have read this application and state that the TOTAL FEE
b f 5 correct. I agree to comply with all County
ri
crd a a late laws regulating Electrical wiring, and
i I ri representatives of this County to enter upon
mve- , uped ppperty for inspection In poses. r SEE REVERSE FOR EXPLANATORY LANGUAGE
�S* Aid Permittee Date