HomeMy Public PortalAbout9132 LONGDEN AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 10/81 AIp �n �����®(aP (Z®� 2n,�������n �2(�1��1�5�
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"I-he"' affirm that I have a certificate of consent to self � ,
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
gr c2 Fertified copy thereof (Sec ,3800, Lab C ) .
P v No, Compan; FOR APPLICANT TO FILL IN' JOB1 N
IL�J Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS J
ElCertified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft $ — $ LOCALITY
tion department Multi-family Sq Ft NEAREST
Residential Swimming Pools r -4 CROSS ST`I�8b OWNER O
RDate Applicant
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL
Outlets Rec Light IS"
COMPENSATION INSURANCE ADDRESS
s section neednot completed if the work involved b First 20
(Thitit b
p Y Total No Additional � - CITY5,4�3Tel No. g� 0 b
the permit is,for one hundred dollars ($100)or less.)
I certify performance of the work for which this PLAN CHECK
- Y that in'the P , APPLICANT'
permit is issued, I shall not employ any person in any manner,
so as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20 ADDRESS
' - Total No� Additional .
Date ' - Applicant CITY 44 T 1 a
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, after 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 I I 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 Corid REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCE BY �-
Power Apparatus& Large Appliances r
and Professions Code,and my license is in full force and effect O 0
Size&Type HP, KW, KVA, or KVAR �L V
License Number �Lic Class Up to 1 Incl FINAL
DATE VA DATION O
�11�l1 V l tBro�Date _3 4_8� Over 1 to 10 Incl ````���<<<< e/ V
Contractor Over 10 to 50 Incl
FINA W
EJ I am exempt under Sec Over 50 to 100 Inc BY 0
B&P C tifor this reason Over 100 z
Date ervices, Swbd , MCC& Ponelboards D
0 -200 Amp Under 600V 419.5 A
Signature 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp'or Over 600 V # o o o o o 2
Exemption for Reg Maint Elect
SINGLE FAMILY ;) o 0 41.2 5
HOME OWNER-BUILDER DECLARATION Temp Power Pole 8 Appurtenances
y p Sign with One Branch Circuit o 0 0 v
I
hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 4 1.2 5
_aw,for the following reason (Section 7031 5, Business and
rofessions Code)
I, as owner of the property, will do the work and the Misc Conduits& Conductors 031 0-t86
structure is not intended or offered for sale (Section Or (See Comple a Fee,Sc edule)_
+' 7044, Business and Professions Code) h cki A00 AaAe 5ERVICE,
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
e performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
c 3097, Civ C )
PLAN CHECKING FEE
xer's Name
PERMIT ISSUING FEE
per's Address
�rtify that I have read this application and state that the TOTAL FEE
eve information is correct I agree to comply with all County
finances and State laws regulating Electrical wiring, and
reby authorize representatives of this County to enter upon
e bove-mentionej property for inspection purposes
_ 2-U
7 CC/ SEE REVERSE FOR EXPLANATORY LANGUAGE/O+b
gnature of Permittee Date