HomeMy Public PortalAbout9156 JAYLEE DR_Electrical_12/17/1991_outlets,fixtures WORKERS'.COMRENSATIONDECLARATION 76-663 to/at APP B� ATION •2®R E ECTMICA PERWT'
I hereby affirm,that I have a certificate of consent to self insure,
CE-806G I� LLe l� Ir L� l� l� LLQ LS
or aicertificate-of Workers' Compensation Insurance, or a certified COUNTY OF L•O&ANGELES BUILDING AND SAFETY
copy thereof (Sec.3800.Lab.C.)
Policy No:a7J��{�!S&' Company�i�G F���' FOR APPLICANT TO FILL IN JOB
Q Certified copy is hereby.;furnished EACH NO. FEE ADDRESS
,. � � New Residential Bldgs.:& Pools
1 & 2-Family,Sq.Ft. $ — $ LOCALITY"-Q�pL` 1 -�
Certified copy is filed -with the bounty building inspection —
department:. C-b ';.v5• Co-!g;. Multi-family Sq.Ft. CROSS NEAREST ST."'
i L o�L�� Residential Swimming Pools OWNER OR
y,Date Applicant (k {�
.. • FIRM NAME A•fbd7G�,'G,(L 4
CERTIFICATE OF EXEMPTION`FROM`WORKERS '+i•,. MAIL
COMPENSATION INSURANCE Outlets:'Rec Light Sw ADDRESS
(This section need.not be cpm leted"if the work invol4ed'b the First 20 �
P y Total No. Additional" CITY—T.; Tel.No:
permit is for one huridred dollars($100)or less.)
I certif ;that in,•the erformance'of the-work for which this-permit PLAN CHECK
.Y P P _ _ APPLICANT
is-issuedr.l shall not,employ any person in any manner so as to
become subject to'the Workets'-Compensation Laws. Lighting Fixtures -First 20" ADDRESS
Additional ' p
Total No. (4 CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP, PERMIT
NOTICE TO APPLICANT:- If;; after. making this..Certificate of
Exemption;you should become subject to the,Workers'Compensatiori Range_`Heater DW.; _ APPLICANTt7 1,So/5 Ont S a` �e
provisions of the.Labor Code;•you must forthwith comply with such Oven Dryer _r W.M. ADDRESS j j;4
provisions or this permit shall,be deemed revoked., Top FAU W.H. CITY Tel.No..
LICENSED CONTRACTORS DECLARATION " Hood _ Fan •Other' 9 ^, �r a*� '3-t 3x9
I hereb affirm;that_I am-licensed`under provisions of Cha ter 9 LICENSE OR
Y' p Disp: ROOni Air Cord, _
(commencing with Section 7000) of Division•3,of,the Business and REG.NUMBER Class. _ A
Professions Code,and my license is in full force and effect. DISTRICT NO. P CESSED BY '
Power Apparatus& Large Appliances - p
�[ �Q Size& Type HP,KW,KVA,or KVAR �®,
License Number Tf �1 µ' Lic:Classes "' Up to 1 Incl. FINAL U
Over 1 to 10 Incl. —
DATE
/ a VALIDATION.
Contractor GCAV R iiy .K r'C.. Date ✓ Over 10 to 50 Incl. FIN
_
❑ I am exempt.under Sec: „ Over 50,to 10,0dric. .'... BY AL `.' i r
U.
W .
Over 100 CL
B.&P.C. for this reason Cn
Services, CC&Panelbcards .
y Date: er 0-(ZOO ADW.Under 600,V U D
Signature 201 - 1000 Amp.U4er'600 V
Over 1000 Amp.or Over 600 V:
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power-Pole &•Appurtenances
HOMEOWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
--
for the following reason(Section 7031.5,.Business and
.Professions Additional Sign Branch CircuitsT '
Code):
�_
.. !
❑ Misc.Conduits&Conductors r _ r_.
I,as owner of the property,will do the work and the structure _
is not intended or.offered for sale (Section 7044, BusinessOther(See Complete Fee Schedule)
,_!TA-g� 3 1 r
and.Professions Code). D
CONSTRUCTION LENDING AGENCY. '' HE)K
I hereby affirm that there is a construction lending agency for the �.H
performance of the work for which this permit is issued(Sec.3097, PERMIT'FEE (Sub-Total) '
Civ.C.).
PLAN CHECKING FEE -
Lender's Name ttl,F�° ( I')�I l•i.• i= 1f 7;$
PERMIT ISSUING FEE' ,5 �r rM j_
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
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 ,
property for inspection puQ�rposes.� SEE REVERSE FOR EXPLANATORY LANGUAGE
(� C ex Cc.w,i
Signature of Permittee Date