HomeMy Public PortalAbout9453 LONGDEN AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 78-883 ; 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm'that i have a certificate of consent to self insure, CE-808G
or a certiificate„of Workers' Compensation Insurance, or a Certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ElI tel.
Certified copy is hereby furnished. New Residential Bldgs.&PoolsADDRESS
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EACH NO. FEE
Certified copy is filed with the: county building inspection
1 &2-Family,Sq .Ft._ l arg!2 $ — $ LOCALITY r G
NEAREST r
department. Multi-family Sq.Ft. CROSS ST. � � W+rY .
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME 09&%)
CERTIFICATE OF EXEMPTIONOM WORKERS' Outlets:Rec_Light_.Sw.— MAIL
COMPENSATION INS ANCE ADDRESS
(This section need not be completed if the work Involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No.
I certify that in the performance of the work for which this permit PLAN CHECK
fy. p p APPLICANT
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 Fixed Appliances Not Over 1 HP PERMIT A
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT �A � �l C.
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W.
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS IZZ
provisions or this permit shall be deemed revoked. Top ;— FAU _ W.H. �A
CITY
LICENSED CONTRACTORS DECLARATION Hood— Fan _ Other_ hp-CA-DIA Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 Disp.,— Room Air Cond.• LICENSE OR -66
(commencing with Section 70001 of Division 3 of the Business and REG.NUMBER 3�+ � r Class.gr,_(O
Professions Code,and my license is in full force and effect. DISTRICT N P S D BY
Power Apparatus&Large Appliances �( d
Size&Type HP,KW,KVA,or KVAR !V� Q
License Number Iy Lic.Class Up to 1 Incl. FINAL I , V
1f�� � �1E c &I—may`9I Over 1 to 10 Incl. DATE VALIDATION Q
Contracto ate "✓ Over 10 to 50 Incl. FINAL I VVV��� V
❑ lam exempt.under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 a"In
Services,'Swbd.,MCC&Panelboards ® Z
Date: 0-200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
n
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with.One Branch Circuita
I hereby affirm that I am exempt from the Contractor's License Law AST°4
for the following reason(Section 7031.5,Business and Professions Additional,Sign Branch Circuits -� (07 °01
Code): I
❑ I,as owner of the property, do the work and the structure _
is not intended or offered forr Other(See Complete Fee Schedule)Misc.Conduits&Conductors 1 ITEMS
sale (Section 7044, Business ® TOTAL 88.00
and Professions Code). � `���� 08.9.��
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CHANGE °[)[I
performance of the work for which this.permit is issued(Sec..3097, PERMIT FEE (Sub-Total)
Civ.C.)..
PLAN CHECKING FEE
Lender's Name I 0000—OG01 4/23/90
PERMIT ISSUING FEE 0260 1 Ati1U�4L)
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE t
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
proleinsp ction purpo SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigermittee Date i