HomeMy Public PortalAbout10324 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to self CE-806G 7�
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY U
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB yy �) !1
Certified copy is hereby furnished. New Residential Bldgs. & Po I EACH NO. FEE ADDRESS /03 _Z c-.
1 & 2-Famil S Ft. w — $ LOCALITY
�ertified copy is filed with the county building inspec- y. q. —
tion depar ment. Multi-family Sq. Ft. NEAREST ^ !
p(Z f��j � Residential Swimming Pools \t CROSS SL L `TT
Date / d Applicant \ - OWNER NAME
PF FIRM NAME C
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.= MAIL
COMPENSATION INSURANCE ADDRESS
s section completed if the work involved b First 20
(Thisction need not bp Y
the permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Tel. No.PLAN CHECK
I certify that in the performance of the work for which this 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 GA DCS �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 JZ ,G 44olf AV e—
with comply with such provisions or this permit shall be Top _ FAU —W.H: —
deemed revoked. CITY ��, lQ Tel. No.44447 S7�j
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Z-,7,0 9 `o Class. !v-f O
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PRO D BY per„'
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances O
® Size&Type HP, KW, KVA, or KVAR �[ U
License Number32'!:F0g(0 Lic. Class C'
Up to 1 Incl.
FINAL
q—�,_-+ lA &[EC( "VOS�ss� Over 1 to 10 Incl.
Contractor PYYums Date ( ""� DATE V 'IDATION
❑ Over 10 to 50 Incl. FINAL ".1,1
I am exempt under Sec. Over 50 to 100 Inc. BY fl'
N
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 # 0
0 0 0 0
❑ Over 1000 Amp. or Over 600 V I o o° o86.50
oo
Exemption for Reg. Moint. Elect.
SINGLE FAMILY Temp. Power Pole &Appurtenances 00.2 5
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
Law for the following reason (Section 7031.5, Business and
Professions 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)— ►
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
Lender's Address p
I certify that I have read this application and state that the TOTAL FEE b �6
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
the ve-mentioned prty or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
j0 3 G<
Signatur of Permittee Dae