HomeMy Public PortalAbout5815 KAUFFMAN AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I h'dCE-806G affirm that I have a certificate of consent to self CE-606G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof ( S 3800, L C-)
Policy No.,�C mpany FOR APPLICANT TO FILL IN JOB
Certified co s hereby furnished. EACH NO. FEE ADDRESS ^fir
copy Y New Residential Bldgs. P s
LOCALITY e
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $
tion department. Multi-family Sq. Ft. — NEAREST
A �e Residential Swimming Pools CROSS OWNER T.
Date Applicant
_ FIRM NAME OYi
CERTIFICATE OF EXEMPTION FROM WORKE -� MAR
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Outlets: ReS
COMPENSATION INSURANCE ADDRESS a
(This section need not be completed if the work involved by Total No. AddiFirst tional CITY Tel. No.ayc^ )
the permit is for one hundred dollars($100)or less.) LJ
I certify that in the performance of the work for which this PAL PNC H
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. CITY TelNo.Additional
.
Date Applicant `� RO� ' ~�
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. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ OtherT
LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air tC��oyn6d. Class. r
® & /� REG. NUMBE t1
(commencing with Section 7000) of Division 3 of the Business Appliances e AppDISTRICT Ne)._ PROCE ED Y
aratus & Large and Professions Co�fe,and my license is in full force and effect. Power App
Size &Type HP, KW, KVA, or KVAR'
License Numbe, Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 Inc[. DATE ` VALID ION O
Contractor Date Over 10 to 50 Incl. / W
❑ FINA
I am exempt under Se Over 50 to 100 Inc. BY U)
B.&P.C. for this reason Over 100 Z
Serv' C& Ponelboords
Date: n 9W A—--t�der 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole & Appurtenances # 4 3 9 0
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 ° 2 9
Law for the following reason (Section 7031.5, Business and
Professions Code): x
Misc. Conduits&Conductors o ° o 2 9,.0 0 v
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ ® 0 46 0 8=8 6
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.). YZ
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
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
t above-m toned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Per i ate