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Home My Public Portal About11011 GREEN TREE LN_Electrical__ WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT I herebyCE-806, affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING•AND SAFETY or a certified n copy ihereof (Sec. 3800, Lab. C.) -� �, K) ' Polic !N(,aaf,Company T Gfi_\��C�Il�\ FOR APPLICANT TO FILL IN JOB Jk Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS L _ ��Y►� � ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALIT tion department. Multi-family Sq. Ft. ©-, NEAREST �1 r Residential Swimming Pools CROSS ST. — _ Date r/n7 Applicant &_�deo g OWNER OR FIRM NAME w CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw. > MAIL COMPENSATION INSURANCE 20 ADDRESS `) ilv s section need not be completed if the work involved b First (ThitinP Y Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN C ECK I certify that in the 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 Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS 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 )C. 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 with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. CITY C T.I. No<: ' LICENSED CONTRACTORS DECLARATION Hood _ Fan _ OtherLICENSEO I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER �� Class. (commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR SED BY >, and Professions Code,and my license is in full force and effect. r IL -7 Size &Type HP, KW, KVA, or KVAR' License Number `5 r q�S-A Lic. Class C- Up to 1 Incl. FINAL t; Contractor�� Fl )�C7 Dates ume, Over 1 to 10 Incl. DATE _ ��-� r VALIDATION EJOver 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY/-,yLU Over 100 B.&P.C. for this reason - of Services, Swbd, MCC& Panelboards Date: 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Professions Code): 2 2 3 4, 7-A ❑ I, as owner of the property, will do the work and the Misc. Conduits & Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— , # o 0 o o 02 7044, Business and Professions Code). o 0 9 a 5 8 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for o o - 9 5 8 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). 0627-' 85 PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address 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 above-mentioned,PIRPerty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -- ) 1 1 _ 4__ -) _1� Signa of Permittee Date