HomeMy Public PortalAbout9180 JAYLEE DR_Electrical_1/14/1985_outlets,fixtures WORKERS' COMPENSATION DECLARATION'- 76A663 10/81 0 0 0 0 0 0
I hergby offirrn that I have a certificate of conse�t to,self` CE-806G APPL XION FOR ELEI � UC AL pIEQM57
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof'(Sec. 3800, Lab. C.
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools • EACH. NO. FEE ADDRESS JJBQ :'A r
❑ 1 & 2-Famil S Ft. $ _ $ LOCALIT
Certified copy is filed with the county building inspec- Y. 9•
tion department. Multi-family Sq. Ft. NEAREST t
Residential Swimming Pools CROSS ST. ,. La
Date Applicant OWNER OR Q
FIRM NAME w/T
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec-(.—Ligh�Sw. MAIL
COMPENSATION INSURANCE ADDRESS V r
/ +� First 20 /
(This section need not be completed if the work involved by Total NoLl� CITY Y/ Tel. No.
the permit is for one hundred dollars ($100)or less.) Additional r ��.�" rT
performance of the work for which this PLAN CHECK
I certify /
that in the P PPLICANT J
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 L ADDRESS-
Additional
_ '
Total,No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
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
with comply with such provisions or this permit shall be Top . _ FAU —W.H. —
deemed revoked. Hood Fan _ Other_ CITY Tel. No.
, LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class:
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE E BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances O , 0.
b
Size & Type HP;KW, KVA, or.KVAR' .®
License Number Lica Class Up to 1 Incl., FINAL V
Over 1 to 10 Incl.. DATE L� �� VALID T id
Contractor Date Over 10 to 50 Incl. �l o
FINAL U
F] I am exempt under Sec. Over 50 to 100 Inc. BY CL
B.&P:C. for this reason Over 100 of
Date:
Services, Swbd.,-MCC& Panelboards D� .2 1.3.3.4'A
0 -200 Amp. Under 600 V '
Signature 201 1000 Amp. Under 600 V #'o'o'o'o o'2
❑ Over 1000 Amp. or'Over 600 V i
Exemption for Reg. Maint. Elect. 2A 7 Jr
SINGLE FAMILY Temp. Power Pole&Appurtenances o'o o 2 1.7 5 5'
U
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 O 1, 4=$5
Law for the following reason (Section 7031.5 Business and
Pro essions Code):. ,
I, 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)_ D
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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.).
PLAN CHECKING*FEE -
Lender's Name
PERMIT ISSUING FEE o .50
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
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S gnature of Permittee' -Date '