HomeMy Public PortalAbout9850 LA ROSA DR_Electrical__ WORKERS'COMPENSATION DECLARATION - ,D,B, APPLICATION FOR ELECTRICAL PERMIT {�
I hereby affirm that I'fiave CE
a certificate.of consent to self insure, CE-806sGSG �J
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �O /
L
❑ EACH NO. FEE -DDRESS
Certified copy is hereby furnished. New Residential Rltlgs.8 Pools LOCALITY ��pp
❑ Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ — $ E C//
department. Multi-family Sq. Ft. NEAREST
CROSS ST.
Date Applicant - Residential Swimming Pools OWNER OR
_ FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Red— Light Sw. MAIL
COMPENSATION.INSURANCE. ADDRESS
(This section need,not be completed if the work involved by the First 20 , Tel.No.
/
PL
permit is for one hundred dollars ($100)or less.) Total No. Additional i CITY reiY>z �l..�r 1
'I AN
(.certify that in the,performance of the work for which this permit � I `. �
�v APPLICANT
is issued, I shall not employ any person in any manner so as tobecome subject to the Workers'Cc pensaho La s Lighting Fixtures First 20 I ADDRESS
Additional 1
yq I Total No. CITY TeL No.
Date L [l/ Applicant �•
- Fixed Appliances Not Over 1 HP PERMIT-
NOTICE TO APPLICANT: If, after m ing this edifies of /,` / c
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT GCl}� L. S� 'f PiJ
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS,O6 .,�
provisions or this permit shall be deemed revoked Top — FAU _ W.H.
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
1 hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR p
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. .— REG.NIJMBER��JI 7L4 Class6—/0
Professions Code,and my license is in full force and effect. Power Apparatus & Large Appliances DISTRICT NO G PROCESD BY
SEQO
��[[ Size& Type H �
P, KW,KVA, or KVAR O
License Numben�ll 74 Lic.Class C It Up to 1'Ind. - FINAL
Over 1 to 70 lricl. DATE VALIDATION 0
Contractor—/ ( Date Over 10 to 50 Incl (/ �
❑ am exempt under Sec. '3�— Over 50 to 100 Inc. FINALBY tt W
BBP.C. for this reason Over 100 '� y HC�;T�B d
N
Date: Services,Swb200 A MCC d Panelboartls J;,3} y;
)% 0- 200 Amp. Under 600 V D� ® ! EEIv
Signature 20 - 1000 Amp.Under 600 v - - - i IITEMOve
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg. Maint.Elect. - T[IfAL
SINGLE FAMILY Temp. Power Pole& Appurtenances NECKFi.
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit _
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits - CHANGE ��`'v,ll,1Q
for the fallowing reason (Section 7031.5, Business and Professions -
Code):
❑ .I�I,as owner of the property,will do the work and the structure Misc. Conduits & Conductors [II 25
and
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule)
and Professions Code). '- - 3O05 i AM 9:51
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(Sec.3097, PERMIT FEE (Sub-Tdtal)
Civ. C.).
PLAN CHECKING.FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
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 in ecti purposes.
- e SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature bJ Permittee Date , ,_