HomeMy Public PortalAbout9445 LAS TUNAS DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81
I hereby affirm that I Have a certificate of consent to self'insure, CE-806G ' APPLICATIONFpOR ELECTRICAL PERMIT
) 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 ~� •f '"• FOR APPLICANT TO FILL.IN JOB
❑ Certified copy is hereby furnished., New Residential Bldgs.& Pools' EACH NO. FEE ADDRESS ` C '� l• r '• , '; / < f� ,
'i 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY
Certified copy is filed with the county building,inspect ion — NEAREST;
department. Multi-family Sq. Ft.
CROSS ST.
Residential SwimmingPools
` Date Applicant - ' WNER OR
'FOIRM NAME - '
F Ki
-CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: MAIL
—
' COMPENSATION INSURANCE.- Rec Light Sw. ADDRESS'
This section need not be completed Wthe work involved by'the First 20 '
permit is for,one hundred dollars($.100)or less.) Total No. Additional CITY .`-' Tel No.,
'PLAN CHEC
.1 certify thain the performance of the'work work:for which this permit APPLICANT K
t a
is issued, I shall not employ any person in any manner so as to
\.,Ex�m�tibn,
ecome subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS AdditionalTotal No. CITYTel No.ate Applicant
Fixed Appliances Not Over 1 HP • PERMIT
OTICE •:TO APPLICANT:,-If; after making::this Certificate, of you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT
rovisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS
rovisions or this permit shall-be deemed revoked. TOP. FAU _ W.H. CITY TeL No.
LICENSED CONTRACTORS DECLARATION Hood Fan Other_'hereby affirm that I am licensed under•provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR Class. t
Pr ommencing with Section 7000) of Division 3'of the Business and REG.NUMBER
fessions.Code,and my license is in full force and effect. DISTRICT NO s PROCESSED BY
Power Apparatus& Large Appliances P 0
., f Size& Type HP,KW,KVA,or KVAR ;:,, f Yi r ' W
Eicene Number Lic.Class Up to 1 Incl FINAL ,. --I
Over 1 to 10 Incl. DATE VALIDATION,
j. Contra for n. ,. 2 Date
❑ a $ Over 10 to 50 Incl. FINAL
m exempt under Sec. Over 50 to 100 Inc. BY.
B' 'P.C.for`this reason Over 100 0
Services,•Swbd.,MCC&Panelboards ILLI
Date-
.
0 200 Amp. 600 V R r^ W
i
Si nature 201 - 1.000 Amp.Under 600 V I
❑ Over 1000 Amp.or Over 600 V
Ek 4NO p 0>i
mption for Reg.Maint.Elect.
I i O r<t 1�1 C�r"
_•.. .'
SINGLE FAMILY Temp.Power Pole& Appurtenances I,��f Ir �t Li,•; ,
HOME OWNER-BUILDER DECLARATION
I hereby a Sign with One Branch Circuit
firm'•that,I am exempt from the Contractor's License Law`
for the foll_ Additional Sign Branch Circuits
Code); wing reason(Section 7031.5, Business and Professions
I,as Conduits andsc.Miits&Conductors
is not Other(See Complete Fee Schedule) '
twner of the property,will do the.work and the structure
;'and P intended or offered for sale (Section 7044,.Business ,
fessions Code).
yCONSTRUCTION LENDING AGENCY
I hereby..affirn+,•that there is a construction lending'agency for the'
performance ..the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) �`<"•
s Civ.C:).
+ PLAN CHECKING FEE
Lender's Name '-
PERMIT ISSUING FEE
Lender's Addresst:.
I certify that I haTOTAL FEE
.
TOTAL this application and state that the.above t
information is corrt,ct. I;agree,to comply with all.County ordinances '
and State laws :..,gulating Electrical wiring, and hereby authorize
representatives of 'this•County to enter upon the above-mentioned
property for insp ction�Purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PFi'
6r6jwmittee ti Date