HomeMy Public PortalAbout10711 FREER ST_Electrical__ WORKERS'COMPENSATIONDECLARATION 76A663
APPLICATION FOR
ELECTRICAL PERMIT
CE-8
I hereby affirm that I. have 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 FILL IN JOB
Policy No. Company EACH NO. FEE ADDRESS `�
New Residential Bldgs.&Pools
a Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY C
❑ Multi-family Sq. Ft. — NEAREST Cr Iu
Certified copy is filed with the county budding inspection CROSS ST 6 1 e,p� &-
department. Residential Swimming Pools OWNER OR `
FIRM NAME �Q SC jL
-'Date Applicant Outlets Rec_Light_Sw MAIL
First 20 1 ADDRESS �-3cL[s
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY ;�/` Tel NoJy
COMPENSATION INSURANCE C� "� }
PLAN CHECK CL
(This section need not be completed if the work involved j APPLICANT O
r U
by the permit is for one hundred dollazs_($100) or less.) Lighting Fixtures First FADDRESS
Total No. Additional 0
I certify, that in the performance of the work for which this CITY Tel No. F_
Fixed Appliances Not Over 1 HP U
permit is issued, I shall not employ any person in any manner PERMIT ` LU
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANTAQ C a
Oven Dryer_W.M._ ADDRESS `f, - S to
Z
DatedZ
7:52 Applicant /TSN � t C Top FAU _W.H. n
Hood Fan _Other_ CITY fC�se f
C Tel No �� / 1r
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond._ LICENSE OR �/
Exemption, you should become subject to the Workers' REG. NUMBER 96 -/-3 Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT.NO. PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&'Type HP, KW, KVA,or KVARIr
Up to 1 Incl.
FINAL rr11
Over 1 to 10 Incl. DATE 1 � VALIDATION
LICENSED CONTRACTORS DECLARATION .
• Over 10 to 50 Incl.'
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 V
effect. Services'
License'NumberE326s�LlLic. Class—C >;i 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
ContractorAAI.-'r-�l£_GTa di Date >>'-,;1,'—J'7,2— Over 1000 Am P.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 and Professions Code): z,520,5 A
Misc.Conduits&Conductors s
0 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— # o,o)oio 0 2
structure is not intended or offered for sale (Section
7044, Business and'Professions Code). - 2.15 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is "a construction lending agency .oho o,2 15 0=
for, the performance of the work for which this permit is
PERMIT FEE (Sub-Total) 07,issued (Sec. 3097,Civ.C.). � - � 2:7-8 2
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
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 regulatin Electrical wiring, and
hereby authorize representatives of t bt County to enter upon
the abov endo ed property for in ectton purposes; SEE'REV.ERSE FOR EXPLANATORY LANGUAGE
gnat re Per ttee ate