HomeMy Public PortalAbout6403 GOLDEN WEST AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-863 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G
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. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
E] Certifiedcopy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE
❑ 1 & 2-Family,S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspection y q
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR 1
Date Applicant FIRM NAME i
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light"_ Sw. — MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20 CITY Tel.No.
N
Total Additional –
permit is for one hundred dollars($100) or less.) To '
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
is issued, I shall not employ any person in an manner so as to
become subject to the Workers'Com atio aws- LightingFixtures First 20 ADDRESS
p1 � � Total No. Additional CITY Tel.No.
Date + Applicant ' Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
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.
LICENSED CONTRACTORS DECLARATION Hood Fan OtherCITY Tel.No.
_
hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. .DISTRICT NOPROCESSED BY
Power Apparatus& Large Appliances U
Size& Type HP,KW,KVA,or KVAR _.� `"
W
License Number Lic.Class Up to 1 Incl. FINAL --�
Over 1 to 10 Incl. DATE /VALIDATION Ii
Contractor Date Over 10 to 50 Incl.
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. gY �
B.&P.C.for this reason Over 100 p
Services,Swbd.,MCC&Panelboards ►
a
Date: 0-200 Amp.Under 600 V 14,11
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V w + a K
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances a '
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law k • -
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
od ):
� r
I,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) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
repr ntativea"of this County to ente upon the above-mentioned
rp7y for sp,ctior'purposev SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date