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HomeMy Public PortalAbout10815 FREER ST_Electrical__ r WORKERS' COMPENSATION DECLARATION 20A019DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O ' I hereby affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy hereof (Sec. 3800, Lob.-CC.�- .) Policy No.�Company Ul/'Y� FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.� $ i — $ / LOCALITY L� NEAREST y i �� , tion department. Multi-family Sq. Ft. CROSS ST19 . L /�/_0022— _� CIO I //f' Residential Swimming Pools OWNER OR Date Applicant //stfL"{.� FIRM NAME , CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL I / 0 COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. Additional CIT j Tel. No f the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in .he performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Work6rs'Compensation Laws. Lighting Fixtures First 20 ADDRESS ' Additional Total No. CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT APPLICATION 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 10a y with comply with such provisions or this permit shall be Top — FAU W.H. — deemed revoked. CITY , Tel. No.,?/ , Hood Fan —Other— LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. Room Air Cond. REG. NUMBER ' Class. I hereby affirm that I am licensed under provisions of Chapter 9 �` (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR SED BY and Professions Code,and my licen a is in full force and effect. a Size 8 Type HP, KW, KVA, or KVAR ��d� �-� o License Number Lic. Class Up to 1 Incl. FINAL U Contractor. /��9ate I Over 1 to 10 Incl. DATE I _ Z VALIDATION Cr ElOver 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. gY U O100 LL B.&P.C. for this reason Over a Services, Swbd., MCC& PonelboaZrds Z Date: 0-200 Amp. Under 600 V 000, Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ``• _ IL r !•1 o Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): ;trs 2,4o7=1 ❑ Misc. Conduits& Conductors I, as owner of the property, will do the work and the i T>vs'_; structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). t - CONSTRUCTION LENDING AGENCY 1 - I hereby affirm that there is a construction lending agency for C `'E'�'1`' the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) CHH�j13G o1(yl (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address TOTAL FEE /y�� ?2; ni vis%! I certify that I have read this application and state that the 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 the above-menti ned property for inspection p rpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE { gnat f Permitt e D to ©s