HomeMy Public PortalAbout8802 HERMOSA DR_Electrical__ WORKERS'COMPENSATIONDECLARATION 76A663 6G (2-80) APPLICATION FOR ELECTRICAL PERMIT {�
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[,hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES y--BUILDING AND SAFETY
insure, or @ cyrtificate of-Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3600,Lab. C.) /
FOR APPLICANT TO FILL IN
Policy No. Company New Residential Bldgs. &Pools EACH NOJ FEE DRESS
Certified copy is hereby furnished. 1 &2-Family.Sq. Ft. $ — $ LOCALI Y
❑ Multi-family Sq. Ft. — NEAREST -
Certified copy is filed with the county building inspection CROSS ST C
department. Residential Swimming Pools - OWNER OR /yam '
-7++ll FIRM NAME Q F/' O e
Date Applicant Outlets: Rer;Z Light o Sw.10 IS._ / MAIL /"
Firstf 'wd G /G A[Al ST
" o J%-�ETj�C
CERTIFICATE OF EXEMPTION FROM WORKERS' Toial No. A 1 dditional '�-'� 6CITY
COMPENSATION INSURANCE - �y �, pLgN HECK Tel No. d
(This section need not be completed ifthe work involved c7 APPLICANT O U
by the permit is for one hundred dollars (5100) or less.) Lighting Fixtures First 20 'ADDRESS
Total No. 1,e Additional / O
I certify that in the performance of the work for which thisCITY •/ Tel No.
permit is issued, I shall not employ'any person in eav manner Fixed Appliances Not;Over 1 HP F—
PERMIT
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT Wd
Oven _ Dryer_W.M. ADDRESS
Top _ FAU _W.H.._ ?
Date Applicant CITY Tel No.
Hood Fan _.Other_
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond._ �(<_0 LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code, you most forth- Power Apparatus& Large Appliances DISTRICT NO. PR E BY/J
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR r'7�
Up to 1 Incl.
FINAL
Over 1 to 10 Incl. I
DATEll
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LICENSED CONTRACTORS DECLARATION VALIDATIl
Over 10 to 50 Incl.
1 hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- I _ Over 100
ness and Professions.Code, and my license is in full force and
effect. Services / /I4t'4gl �1 //
License Number Lic.Class 0-200 Amp. oder 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
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1, as owner of the property, will do the work and the Mise Conduits Pete Fee Schedule)—
Other (See Complete Fee Schedule)— ��
structure is not intended or offered for sale (Section ,r
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY r
1 hereby affirm that there is a construction lending agencyI
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for the performance of the work for which this permit is PERMIT FEE (Sub-Total) ••1 „ / �"��•
issued (Sec. 3097,Civ.C.). `
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Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) -•, (o— /
Lender's Address
PERMIT ISSUING FEE ' /a
I certify that I have read this application and state that the TOTAL FEE.
above information is correct. I agree to cymply with all County
ordinances and State laws regulon g Electrical wiring, and
hereby authorize $resentatives o this Cyou my to enter upon '
the ab n'ed 40 �,Iy f s coon purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGESignature of PermittDale