HomeMy Public PortalAbout9162 FORTSON DR_Electrical__ WORKERS'COMPENSATION DECLARATION - 764663 10/81 APPLICATION FOR •ELECTRICAL PERMIT
CE-SO6G
1-here6y a`fficxr that hove a certificate'.of consent to self insure;
or.a certificate'of Workers'Compensation Insurance, or a certified COUNTY,OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec `3800,Lab C^). "
Policy No:`1 41-63 -. Company, �/ FOR APPLICANT TO FILL IN .,JOB- �J
• ADDRESS'.'" •l�Z �cOri�s(�/
❑ Cerfified copy•is hereby furnished. New*Residential Bldgs & Pools' EACH' NO., FEE
❑r
Certified 'copy is filed with the county building inspection -1 & 2-Family,Sq Ft - _ _ $ $_ LOCALITY
"• NEAREST'
department-
, . -• Multi-family Sq ,Ft —
`' ;Date �B X22 1 .;L G 'Residential Swimming Pools
' ` CROSS ST. I
'Applicant OWNER OR
•- .+ _ - 'FIRM NAME
CERTIFICATE OF EXEMPTION FROM WOR ERS' Outlets:Rec Light �-Sw. MAIL
COMPENSATION INSURANCE � ADDRESS v �.
(This ection need not be completed,if the worinvolved by,the First 20,k '
permit is-foi-one hundred dollars,-($100) or less.) Total No.�� Additional CITY 2 •'.G1 Tel No '
7 5 •4 l PLAN CHECK-"• '
I certify that:in the performance•,of the.work for which this permit APPLICANT-
is,issued,l shall not employ any,person in any manner so•as to
become subject to the Workers'Cons ensation`Laws .' Lighting Fatures First 20 ADDRESS
Total No,
'Additional r;
CITY ; Tel-No
Date ;Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE,,TO APPLICANT If, after making,this •Certificate of
Exemption,you should become subject to,the.Workers'Compensation Range_ Heater_ DW APPLICANT /f c
provisions of the Labor"Code, you must forthwith comply with such, Oven Dryer W.M ADDRESS
provisions,or this permit shall be deemed revoked Top FAU W H,
r, LICENSED CONTRACTORS DECLARATION Hood Fan - .Other_ • o CITY' � jZ _Tel No. tl7k
I•hereby affirm,that•I am licensed under provisions of'Chapter 9' LICENSE OR- /
Dlsp Room Air Cond. •REG'NUMBER �� C7 - - Class/ L
(commencing with-Section'7000) of Division 3 of the Business and l� �� P
Professions Code,and my'license is in full force and effectDISTRICT NO / PROCES BY
Power Apparatus&Large Appliances
���p 2 Size& Type HP,KW,KVA,or KVAR
License Number V 1i'
Lic. Class t .: T Up to 1 Incl fDATE
AL. U
Y QQ TTTT Over 1 to 10"Incl'71
;Contractor-- _Date /�`' 7-4) (�� _ VALIDATION O
Over 10 to 50 Incl. AL _ V
❑ I am exempt under Sec' Over 50 to 100 Inc,- W
B&PCS for this reason Over 100 « N
Services, Swbd,MCC& Panelboards - �. Z
Date. 0- 200 Amp Under 600 V -
'Signature -2 01 - 1000 Amp.-Under 600 V
` Over 1000 Amp or Over 600 V
❑ ` Eicemption foir Reg.'Maint Elect,
SINGLE FAMILY' Temp Power.`Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch CircuitCT a
I hereby affirm that I am m exempffrothe Contractor's License Law • •Q
for the,following reason(Section 7031 5, Business and Professions Additional Sign Branch Circuits.. •e •
C6de . . 3303 1$7.10
ElI,as'owner of the property,will do,the work and the structure Misc Conduits &Conductors
is'not•intended or offered for sale (Section 7044, Business Other(See,Complete Fee Schedule) TCM 1` 'I TEM
�
and,Professions Code) TOTAL 147® 10
CONSTRUCTION LENDING AGENCY - _ CHECK 177010
I hereby affirm that there is a'construction lending agency for the 11r
performancg•of the work for which this permit'is issued(Sec 3097, PERMIT'FEE (Sub-Total) CE _ .„ .00
'Civ C)
PLAN CHECKING FEE L. - 00000001 10/12/95
Lender-'s Name - - n� — 1
.FERMT ISSUING FEE C�
Lender's Address 2762. 1, AM11:15
I certify that I have read this application and state that the above, TOTAL FEE' �Q `'T : `0
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 purposes. ;
SEE-REVERSE.FOR EXPLANATORY LANGUAGE
Signature of Permi to Date = ;