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HomeMy Public PortalAbout9936 LA ROSA DR_Electrical__ �t WORKERS' COMPENSATION DECLARATION CE-806 10/e1 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have o certificate of consent to self CE-8066 insure, ar 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 �1 r Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS J(O ❑ 1 8 2-Fomil q. $ — 4 LOCALITY C t Certified copy is filed with the county building inspec- y, S Ft. ��"'� e_ tion department. Multi-family Sq. NEAREST CROSS ST. Date Applicant Residential Swimming ing Pools OWNER OR ^ FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rrec_ _� MAIL Light_$w._ f, COMPENSATION INSURANCE ADDRESS This section need not be completedFirst 20 Z ( if the work Involved b T Total No. Additional CITY Q0^© t 'c Tel. No.(-/y .. G the permit is for one hundred dollars ($100)or lass.) I certify that in the performance of the work for which this PLAN CHECK P w\ permit is issued, shall not employ any person in any manner APPLICANT so as to become subject to the Workers'Compensation laws. Lighting Fixtures J First 20 ADDRESS Total No. J Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, offer making this Certificate of APPLICANT 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 with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood Fan _ Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCE SED BY and Professions Code,and my license is in full force and effect. d Size 8 Type HP, KW, KVA, or KVAR O License Number Lia Class Up to I Incl. FINAL V Contractor Date Over I to 10 Incl. DATE VALIDATION ❑ Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BV w 100 B.BP.C. for this reason Over � Date: Services, Swbd., MCC 8 Ponelboards ► ? 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp, Under 600 V ❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole 8 Appurtenances 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 c Law for the following reason (Section 7031.5, Business and Professions Code): c ' ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)- 7044, Business and Professions Code). ► c,�_ ' it 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 I certify that I have read this application and stole that the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State lows regulating Electrical wiring, and ereby authorize representatives of this County to enter upon f e bove-me tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIA nature o F P J,mitIee Date