HomeMy Public PortalAbout9915 GARIBALDI AVE_Electrical__ WORKERS'COMP SATION DECLARATION CE 806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
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 tet- �1,. N ,.. i ` ;," L Z �— r�
a certified co thereof Sec.3800,Lab.C. F A V`
Policy No. CompanFOR APPLICANT TO FILL IN JOB
y s '
New Residential Bldgs.&Pools
EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY � �-+ t��
NREST
Certified copy is filed with the county building inspection Multi-family Sq. Ft. CROSS ST V t>0% �U 1� v
department. Residential Swimming Pools OWNER OR
FIRM NAME �j
Date Applicant Outlets: Rec.—Light—Sw. MAIL d
First 201 ADDRESS I Q
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY T'"o. U
COMPENSATION INSURANCE W
PLAN CHECK ,,✓ J
(This section need not be completed if the work involved APPLICANT LL
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Total No. Additional }
I certify that in the performance of the work for which this CITY Tel No.
Fixed Appliances Not Over 1 HP Q
permit i5 issued, I shall not employ any person in any manner PERMIT 0:
so as to become subject to the Workgrs' Compensation Laws. Range_ Heater_D.W. APPLICANT Q
+"` Oven _ Dryer_W.M.
/ ADDRESS d
Dated— ` ( Applicant. "^ r r' '{ l tf Top — FAU —W.H. W
-'1400d _ Fan _Other_ CITY Tel No. )—
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— I ILICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROC SS�BY
Type with comply with such provisions or this permit shall be Size&Te HP,KW, KVA,or KVAR
deemed revoked. I t� '
Up to 1 Incl
Over 1 to 10 Incl. FINAL
LICENSED CONTRACTORS DECLARATION DATE
Over 10 to 50 Incl. VALIDATION
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 Numbed'' L}-c.cClass t „
{, 201-1000 Amp. Under 600 V
Contractor "# Aj " < Date /" f .y s= 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 and Professions Code):
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section " r 4 V �
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY s e
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) w
issued(Sec. 3097,Civ.C.).
Lender's Name t ! 1
PLAN CHECKING FEE (One-Fourth Permit Feel
Lender's Address PERMIT ISSUING FEE N
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
the abo' mentioned property for inspection purposes.d / SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date