HomeMy Public PortalAbout9518 LIVE OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 10ie1 APPLICATIONFOR ELECTRICAL PERMIT
• I hereby affirm,that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certified copy;hereof (Sec. 3800, Lab. C.)
Policy No.•y�J %C�pany ST 7t CO FOR APPLICANT FILL IN JOB — /� �j
❑ EACH NO. FEE ADDRESS AG v
Certified copy is hereby furnished. New Residential Bldgs. & P
1 & 2-Famil S Ft. $ — S LOCALITY ! r e�T
Certified copy is filed with the county building ' spec- y- q —
tion department. Multi-family Sq. Ft. NEAREST
NCROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec MAIL '
COMPENSATION INSURANCE Light Sw._ ADDRESS
First 20
(This section need not be completed if the work involved by Total No. Additional CITY Tel. N
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 employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant c
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. — S
APPLICANT
Compensation provisions of the Labor Code, you must forth- Oven — Dryer _ W.M.— ADDRESSPop P
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood Fan _Other_ CITY Te I. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Dis p' Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PROT_,;�and Professions Code,and my license is in full force and effect.Q Size& Type HP, KW, KVA, or KVAR' * U
License Number - I► 4 Z Lic. Class Up to 1 Incl. FINAL
AS Y A-4* Co ��Cte �"" Over 1 to 10 Incl. DATE
Contractor _ VALIDATION
❑ Over 10 to 50 Incl. FINAL W
I am exempt under Sec. Over 50 to 100 Inc. BY
BAP.C. for this reason Over 100
Services, Swbd., MCC & Panelboards
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 Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm"that I am exempt from the Contractor's License r
Sign Branch Circuits
Si
Law for the following reason (Section 7031.5, Business and Additionalg
Professions Code):
T T. '6!
❑ I, as owner of the property, will do the work and the Misc.. Conduits 8 Conductors a _ .(°
structure is not intended or offered for sale Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code). '-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for `",I' = _1.•t
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 --•- -- f
PERMIT ISSUING FEE ;-•�>
Lender's Address " - e
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
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE'
.3 J 7 2-
Sig e Date