HomeMy Public PortalAbout9208 LIVE OAK AVE_Electrical__ WORKERS'COMPENSATIONDECLARrATION .+ CE866G (2-80)� APPLICATION FOR ELECTRICAL PERMIT
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 u
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
Policy No. New ResidentiaBldgs.&Pools
Company EACH NO. FEE ADDRESS penn
oi ,r f to
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Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. -�D $ — $ LOCALITY &— NAI
Multi-family Sq. Ft. — NEAREST C C
Certified copy is filed with the county building inspection CROSS ST
Residential Swimming Pools
department. OWNER OR
��..,,{{�� FIRM NAME YI
Date Applicant Outlets: Rec'1R±/Light Sw. MAIL
ADDRESS
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITYe G Tel No. 1/
COMPENSATION INSURANCE PLAN CHE Q
APPLICANT r �V 0
(This section need not be completed if the work involved Lighting Fixtures' First 20 ADDRESS
by the permit is for one hundred dollars ($100) or less.) Additional cc
Total No.
1 certify that in the performance of the work,for which this CITY' Tel No. F-
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any mannerPERMIT LU
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT tl
Oven _ Dryer_W.M._ ADDRESS101,40111, Z
Date Applicant Top FAU _W.H.. CITY � Tel No.
Hood _ Fan _Other_ 6
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PR SSED BY
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR
deemed revoked.
Up to 1 Incl.
- FINAL
Over 1 to 10 Incl. DATE /
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl. ('P�
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
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 if
effect. Services
License Number. Lic.Class 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole& Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit -.2 5 9 4,4 A
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits # o o o o o2
ness and Professions Code):
Misc.Conduits& Conductors 2 0 0 4 p,5 0
f\;?"I, 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 o�e 70 4(L 5 0 5
7044, Business and Professions Code).
'CONSTRUCTION LENDING AGENCY 0 8 3 1 8 2
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)
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
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 50
ordinances and State laws regulating Electrical wiring, and
hereby authorize re resentatives of this County to enter upon
the above-men ' ne roperty fo inspection pu#e .
esSEE'REVERSE FOR EXPLANATORY LANGUAGE
Xature of Permittee ' -