HomeMy Public PortalAbout11015 GREEN TREE LN_Electrical__ I
WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, ora certificate of Workers' Compensation Insurance, —>1j COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 338800, Lab. C.)
Polis c�FFt'i,- fir- Company L LX1R MnP�Sk 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.�,— $ — $ LOCALITY
e � �
tion department. Multi-family Sq. Ft. c�C �lyoL NEAREST
W � Residential Swimming Pools CROSS ST.
Date Applicant ��ap7 OWNER OR
1_FM NAME C', fJ G
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAII
COMPENSATION INSURANCE ADDRESS 51,9N,4.
U L
s section need completed if the work involved b First 20
(Thitin d not b
p Y Total No. Additional CITY 1 Tel. No. - '7 '�
the permit is for one hundred dollars ($100)or less.)
that in the performance of the work for which this PLAN CHECK
I certify P 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
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. Hood Fan _ Other_Room Air Cond. CITY ZU�«� Tel. N �S
LICENSED CONTRACTORS DECLARATION LICENSE OR C
��I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ . REG. NUMBER �/ lass.
(commencing with Section 7000) of Division 3 of the BusinessDISTRICT NO. P SED BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances
ss��
1Size & Type HP, KW, KVA, or KVAR' o 0
License Number3G
2 9a*4 Lic. ClassC— Up to 1 Incl. FINAL
NSAC�� Q) Over 1 to 10 Incl. VALIDATION DATE C��
Contracto �--{ `DateJC2 VUC_ Over 10 to 50 Incl. �J
FINA r �
F1am exempt under Sec. Over 50 to 100 Inc. FI
B.&P.C. for this reason Over 100 L/
Date: Services, Swbd., MCC& Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
F1Exemption
1000 Amp. or Over 600 V
Exemption for Reg. Maini. 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 ;223 $ A
Professions Code):
❑
I, as owner of the property, will do the work and the Misc. Conduits& Conductors
# 0 0 0 0 0 2
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code). , 0 - 98.58
CONSTRUCTION LENDING AGENCY 0 0 0 9 8 5 8
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 2 7 8 5
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 1O
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 abov, -mentioned ca rtyV for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu f Permittee Date