HomeMy Public PortalAbout10410 KEY WEST ST_Electrical__ WOgKERS'COMPENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT '14'
CE 806G (2 80)
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
FOR APPLICANT TO FILL IN JOB � j
Policy No New Residential Bldgs &Pools
Company EACH NO FEE ADDRESS va 1 Lv
Certified copy is hereby furnished 1 &2-Family,Sq Ft ��� $ — $ LOCALITY
Multi-family Sq Ft — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department Residential Swimming Pools OWNER OR
FIRM NAME Fill 2 Hnuolj 6 a L1,
Date Applicant Outlets Rec MAIL
_Light_ Sw ADDRESS
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY Tel No
}
COMPENSATION INSURANCE PLAN CHECK, d
APPLICANT O
(This section need not be completed if the work involved _
Lighting Fixtures First 20 Additional
by the permit is for one hundred dollars ($100) or less.) ADDRESS cc
_ o
Total No
I certify that in the performance of the work for which this F zed Appliances Not Over 1 HP CITY Tel No 0
Il-
permit is issued, I shall not employ any person in any manner PERMIT1 W
so as to become subject to the Workers' Compensation Laws, Range_ Heater_D W APPLICANT T I p S a
Oven _ Dryer_W M ADDRESSN
DatelO/q l-R'/Applicant Top _ FAU _W H S N z
Hood — Fan _Other_ CITY ��' �� Tel No
NOTICE TO APPLICANT If, after making this Certificate Disp _ Room Air Cond._ LICENSE OR
Exemption, you should become subject to the Workers' REG NUMBE Class Cr
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO PROC SE�BY
wrtti comply with such provisions or this permit shall be
deemed revoked - Size&Type HP,KW, KVA,or KVAR
Up to 1 Incl FINAL U
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATE '-Ey VALIDATION
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL n
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY
ness and Professions Code, and my license is in full force and
effect Services �/r�Q
e 0-200 Amp Under 600 V ` ' /oC ch�
License Number_ �r � Lic Class �'-��
201-1000 Amp Under 600 V
Contractor� 2 Tl�./ S�Q(�ate �j S� Over 1000 Amp or Over 600 V ,
J - '
HOME OWNER-BUILDER DECLARATION Temp Power Pole& Appurtenances
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's,, Additional Sign Branch Circuits
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code)
Misc Conduits&Conductors
ElI, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section ;_91 807 A
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY e # a'o o a o 2-
1
I hereby affirm that there is a construction lending agency
for the performance of the'work for'which this permit is PERMIT FEE ` (Sub-Total) 2 0 l0 5 2 2 Jr
issued (Sec 3097,Civ C)
Lender's Name PLAN,CHECKING FEE (One-Fourth Permit Fee) ° ° - 52 2 Jr
Lender's Address PERMIT ISSUING FEE
1 1,02,-81
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
/O
Signature of Permittee Date