HomeMy Public PortalAbout9531 LONGDEN AVE_Electrical__ VIfOFSS(E RS'`COMPENSATION DECLARATION -863 ,D,a,
CE-8060 APPLICATION FOR ELECTRICAL PERMIT
C
I hereby affirm th� I. fiave a certificate of consent lo self�1nsure� �•
or a cMIfioate,oP 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
ADDRESS Aje
Certied copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE I LOCALITY
_ $
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. ,OZ S $
department. Multi-family Sq.Ft. NEAREST
CROSS ST. �,
Residential Swimming Pools ,
t-A Q22
Date Applicant OWNER ORFIRM.NAME !
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rao+W-Light�Sw.� MAIL
COMPENSATION INSURANCE ADDRESS 6
(This section need not be completed If the work Involved by the First 20
petmlt is for one hundred dollars($100)or less.) Total No. Additional CITY cm l.E G li=4 Tel.No. 6-G(662.
1 certify that in the performance of the work.for which this permit PLAN CHECK
is Issued, I shall not employ any:person In any manner so as to APPLICANT
become subject to the Workers'Compensation Laws. Lighting,Fixtures First 20 ADDRESS
i Additional
Total No. CITY Tel.No.
Date. Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRES _ J
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
LICENSED CONTRACTORS DECLARATION. Hood — Fan _ Other-- CITY ut G T Tel.No.. &(6.Z
1 hereby affirm that I am licensed under provisions of Chapter 9Disp. — Room Air Condi LICENSE OR Class..
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in.full force and effect. DISTRICT o. PROCE BY
� tPower Apparatus$Large Appliances � ` r•-
Size&Type HP,KW,KVA,.or KVAR r )
License Number Lic.Class. Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE
Contractor Dae
VALIDATION
t
❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. FI W
B&P.C.for this reason l Over 100 N
Services,Swbd.,MCC&Panelboards
Data. 1 0-200 Amo.Under 600 V �'
Signature 201 - 1000 Amp.Under 600 V }
❑
Exemption for,,.Reg. Over 1000 Amp.or Over 600 V.
Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law ACCT.a
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Code): 1 33017 31.011
1,as owner of the property,will do the work and the structure' Misc.Conduits&Conductors 1 ITEMS
is not intended or offered for sale (Section 7044, Business I Other(See Complete Fee Schedule) _
and Professions Code). ► .TOTAL 31-01)
CONSTRUCTION LENDING.AGENCY I CHECK 31.00
1 hereby affirm that there is a construction lending agency for the I
Performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE .010
Civ.C;).
PLAN CHECKING FEE.
Lender's Name Q •0000-0001 5/22/90
_ PERMIT ISSUING FEE
Lender's Address l 0834 1 Ate 9"0
1 certify that i have read this application and.dtate that.the above! TOTAL FEE a .
'information is correct.1 agree to comply with all County ordinances'
and State laws LII ting E al wiring, and hereby authorize'
representativ .o his C ty t enter upon the above-mentioned
property iontr , SEE REVERSE FOR EXPLANATORY LANGUAGE
o rm' a�7 Date