HomeMy Public PortalAbout11020 GREEN TREE LN_Electrical__ WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I'Hereby affirm that I have a certificateCE-806G of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certifieldd.clopy thereof (Sec. 3800, Lab. C�j) ,v C
Policy t�!1 t I;�ompany �a R� Y1ti� FOR APPLICANT TO FILL IN JOB
�ertified co is hereby furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. & Pools
❑ LOCALITY
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ \
tion department. Multi-family Sq. Ft. • NEAREST
4 \ Residential Swimming Pools OWNER OSS T. !
Date 7" Applicant ,
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' OutMAIL
lets: Rec Light Sw._ t� r
COMPENSATION INSURANCE First 20 ADDRESS
`' `• �
(This section need not be completed if the work involved by Total No. CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) Additional 1
PLAN CHECK
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
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
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 t zt
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY Tel. N G
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other—
Disp. Room Air Cond. LICENSE O Class.
I hereby affirm that I am licensed under provisions of Chapter 9 'REG. NUMBER � e—(
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO, PRO
and Professions Code, and my license is in full-force and effect.
r, Size &Type HP, KW, KVA, or KVAR' U
License Number �� /�} 42;�y Lir. Class C-10 Up to 1 Incl.
FINAL
Over 1 to 10 Incl. DATE VALIDATION @9
Contractor t ate_�C tYl� Over 10 to 50 Incl. FIN �
❑ I am exempt under Sec. Over 50 to 100 Inc, BYLU
Over 100
B.&P.C. for this reason to
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):
1, as owner of the property, will do the work and the Misc. Conduits &Conductors
El4
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 2 3 3.A
7044, Business and Professions Code). ► # o o o a o2
CONSTRUCTION LENDING AGENCY 0 0 9 7 2 2
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)
(Sec. 3097, Civ. C.). o a 0 9 7,2 2 c1_
PLAN CHECKING FEE
Lender's Name 0627-85
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
�.. ab ve-mentioned pr ty for inspection purposes.
r
r � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu e f Permitt Date