HomeMy Public PortalAbout11024 GREEN TREE LN_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby 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 copy thereof (Sec. 3800, Lab. C.)
Poli NC_;i xu�Company-tTtalsi r�) of FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldg's. & Pools EACH NO. FEE ADDRESS e
❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft.- 'NEAREST
ROSS ST. C�
C Residential Swimming Pools OWNER OR
Date 6'1 7-S l Applicant —� FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
completed if the work involved b First 20
(This section need not be com p Y Total No. Additional CITY Tel. No.
The permit is for one hundred dollars ($100)or less.)
1 certifythat in the performance of the work for which this PLAN CHECK
e 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 11
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 C> G(
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood Fan _ Other_ CITY Z C� Tel. No. o S
. LICENSED CONTRACTORS DECLARATION LICENSE R
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER -7 Class.C —
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. P�BY
Power Apparatus& Large Appliances
and Professions Code,and my license is in full force and effect. i
Size & Type HP, KW, KVA, or KVAR, O
License Number 2>7q6=1 L� Lic. Class C'-I0 Up to 1 Incl. FINAL
h ,p Over 1 to 10 Incl. DATE 7_ C VALIDATION
Contractor, t ��U\Ci Da1e�r���rm Over 10 to 50 Incl. GJ `j
FIN U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 tot
Services, Swbd., MCC& Panelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
El
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 2 2 3 4'3 A
Law for the following reason (Section 7031.5, Business and
Professions Code): # o o 0 0 0 2
❑ 1, 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)— ► ) ° 1 04,02
7044, Business and Professions Code). o ° 1 0 4 0 2
125
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 627-85
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE Q
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 9 .o
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
r
the ab ve-mentione p ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign t e of Permittee Date -