HomeMy Public PortalAbout10303 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereherebyCE-806 affirm that I have a certificate of consent to self CE-806G
insuPe, •:sr 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 �,y
Certified co is hereby furnished. EACH PNO. FEE ADDRESS 303 �• w�
PY Y New Residential Bldgs. 8 P o A
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. V $ S LOCALITYtion department. Multi-family Sq. Ft. NEAREST
CROSS ST. Sy IL
tp 23 �� Residential Swimming Pools OWNER OR
Date_ Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light ' Sw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY Tel. No.
the permit is for one hundred dollars ($100)or less.)
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT
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. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT A,4ZCA,1C>CA j24F—c7I(*t-G
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 ��j2sj( J
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. CITY (A Tel. No- 4,4-7-57:i
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
LICENSE �j
I,hereby affirm that I am licensed under provisions of Chapter 9 Dis p' _ Room Air Cond. REG. NUMBER 'J'ZJ"dc7 CP Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT N� P� PR E ED BY
and Professions Code,and my license is in full force and effect. vX Size 8 Type HP, KW, KVA, or ICVARV
' �
License Number-5Z5�`�l!����.- Lic. Class 4C— Up to 1 Incl. FINAL' O
Contractor 9"'c C�Date � 3 Over 1 to 10 Incl. DATE 2 VALIDATION w
❑ Over 10 to 50 Incl. FIN
I am exempt under Sec. Over 50 to 100 Inc. B
BAP.C. for this reason Over 100 Z
Services, Swbd., MCC& Panelboards ►
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
�327.6A
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # o o o a o 2
1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and I o o 9(1 5 0
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits& Conductors o 0 0 9 Q 5 0 6
v
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Profess ions.Code). ► I Q 2 4 8 5
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 Q
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
hereb authorize representatives of this County to enter upon
thea ave-mentio a pro ert or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Permittee Date