HomeMy Public PortalAbout9168 JAYLEE DR_Electrical_5/10/1982_outlets, fixtures,pool WORKERS'COMPENSATIONDECLARATION 76A663 /ap.pdpC�AMN FOR EL EC TMICAL�. p�C�l�lr T
CE-806G (2-80)
I herebyaffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY .
insure, or a certificate of Workers'Compensation Insurance,or
a.certified copy thereof(Sec. 3800,Lab.C.) '
FOR APPLICANT TO FILL IN ,Jog C�I _
Policy No. Company EACH NO. FEE ADDRESS t ( � ' '� (/L"L�.
New Residential Bldgs.&Pools
0 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY ie - ,17,C_e ,7 .�
Multi-family Sq, Ft. NEAREST
Certified copy is filed with the county building inspection d CROSS ST �e�at•�a
department. Residential Swimming Pools►/ p RM NAME .br�
Date Applicant Outlets: Rec.—Light Sw. MAIL
First 20 ADDRESS l IA lt�_ n" iea_
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY` �f�6• �ry9'Tel No. �
COMPENSATION INSURANCE PLAN CHECK Q_
(This section need not be completed if the work involved APPLICANT U
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS ` cc
Total No. 4 0
ppP CITY Tel No�
Additional- �
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 H
permit is issued, I shall not employ any person in any manner PERMIT W
so'as to become-subject to the Workers' Compensation Laws. Range_Heater_D.W. APPLICANT tL
Oven _ Dryer_W.M. ADDRESS Z
Date Applicant Top _ FAU _W.H.._
Hood Fan _Other_ CITY el No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power.Apparatus& Large Appliances DISTRICT NO. PROCES ED BY
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR S O
deemed revoked.
UP to 1 Incl.
FINAL
Over'l to 10 Incl. DATE n/
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10.to 50 Incl.
I 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 BY Busi- Over 100
ness and Professions.Code, and my license is in full force and
effect. Services
License Number Lia Class 0-200 Amp..Under 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-
ness and Professions Code): -23929 A
Misc:Conduits&Conductors
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— # 6.o'o o o.2
Xstructure is not intended or offered for sale (Section
7044, Business and Professions Code). / 2 38,50
CONSTRUCTION LENDING'AGENCY
I hereby affirm that there is a construction lending agency o o to 3 8 5.0
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued(Sec. 3097,Civ.C.). 0 5 1;0 8.2
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Len der's,A'ddress PERMIT ISSUING FEE �d
I certify that I have read this application and state that the TOTAL FEE 3.e V
above information is correct.I agree to comply with all County _
ordinances and State laws reg lating Electrical wiring, and
hereby t rize. resentativ f this County to enter upon
the abo - nti ert f r inspection purpo s. SEE-REVERSE FOR EXPLANATORY LANGUAGE
_ 15iv do-2—
Signature of ermittee Date