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HomeMy Public PortalAbout8838 LONGDEN AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A669oFw3 e7 APPUCA NOO N FOR ELECT �CAL PERMT I hereby dffirm that I have a certificate of consent to self CE-806G ' insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or p certified-copy thereof (Sec. 3800, Lab. C. Q Bolicy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS 88�� �D� /0-AL) ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE LOCALITY / ElCertifiedcopy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ L�/Y7 � tion department. Multi-family Sq. Ft. NEAREST CROSS ST. ✓` Residential Swimming Pools OWNER•OR tC Apt Date Applicarit f FFC RM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' © C'SCOMPENSATION INSURANCE Outlet's: Rec�_Light Sw. l] SS [) 1J First 20(This section need not be completed if the work involved by Total No. Additional Z;jne/e 0 Tel. No,p to the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employany person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional � 3 �' Applicant . 'Total No. oZ CITY Tel. No. Date Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after mal ing this ertificote of/ APPLICATION 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— �d CITY �zC Tel. Na!B ,y_ LICENSED.CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. REG. NUMBER �(JClass. 1 hereby affirm that I am licensed under provisions of Chapter (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR SSED BY d and Professions Code, and my license is in full force and effect. Size'&Type HP, KW, KVA, or KVAR � ��j 0 License Number Ca�V Jo.2 Lic. Class f� Up to 1 Incl. FINAL C Over 1 to 10 Incl. DATE �( `( VALIDATION tZ Contractor U-4 Date 3-/5- l Over 10 to 50 Incl. 0 ❑ FINAL I am exemptQ LU under Sec. Over 50 to 100 Inc. BY �J_.��� W B.&P.C. for this reason Over 100 v W Services, Swbd., MCC& Panelboards Z Date: 0- 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby affirm that)am exempt from the Contractor's License Sign with One Branch Circuit ;NC'C 1'. is Law for The following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): `ate=` Ell, as owner of the property, will do the work and the Misc. Conduits&Conductors 1 E GZ f structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ D II n`• 23 30-4 ,Business and Professions Code). s ` �. r .. r!a CONSTRUCTION LENDING AGENCY `-'TE=' -=L(.` 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 !J1-11 0,` i PERMIT ISSUING FEE _-• _ _ Lender's Address /� v0 - I certify that I have read this application and state that the TOTAL FEE 3!7 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 3 8J Signal re of Permittee Date ©s