HomeMy Public PortalAbout10312 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I,hereby,dffirm that I have a certificate of consent to self CE-806G
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 herebyfurnished. New Residential Bldgs. & Pool EACH NO. FEE ADDRESS ' 3
_ LOCALIT
� J
ertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. g — g Y '�
tion deportment. Multi-family Sq. Ft. NEARESTPV
�p n ti 195—Applicant
95; CIF CROSS
Residential Swimming Pools OWNER OR 0� L
Date Applicant4p[A • cc
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' w. MAIL
COMPENSATION INSURANCE Outlets: Rec Light S-20 ADDRESS
First-20 � 'tn � � � -
(This section need not be completed if the work involved by Total No. e\ ' " " CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) Additional
I certifythat in the performance of the work for which this PLAN CHECK
P erAPPLICANT
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 cPtA e� 12Z C
Exemption, you should become subject to the Workers' Range_ Heater—D.W. _ �,i_ ll ^^••__
Compensation provisions of the Labor Code, you must forth- Oven — Dryer _ W.M.— ADDRESS 122�j 7'int6 ' J
with comply with.such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. CITY �t/� Tel. No.La<(7S 7,y
Hood Fan _Other_
LICENSED CONTRACTORS DECLARATION
LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER �L JY� Class.`i--(0
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PRO EDB
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances �''� O
0 _ Size &Type HP, KW, KVA, or KVAR' L� V
License Number.3" 6 Lic. Class G �� Up to 1 Incl. FINAL �
A�� ( Over 1 to 10 Incl. DATE
Contractor l��EkC' t�1• Date 69 7 (f �1 VALIDATION 0
F-1
Over 10 to 50 Incl. FIN W
I am exempt under Sec. Over 50 to 100 Inc. BY �-
fn
B.&P.C. for this reason Over 100 Z
Date: Services, Swbd., MCC & Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ °
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION ;2 3 2 a O A
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License o 0 0 0 0 n Branch Circuits #
Law for the following reason (Section 7031.5, Business and Additional Sig2 )
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits &Conductors o o 8 7, 1 4
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 0 0 0 8 ], 1 47044, Business and Professions Code).
CONSTRUCTION LENDING AGENCYI Q 2 4-H 5
1 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) 7
(Sec. 3097, Civ. C.). 07
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
the ove-mentio ed pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signatur yrof Perrbittee Date