HomeMy Public PortalAbout10165 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION 76-60 10/81
CE-80
6G APPLICATION FOR ELECTRICAL PERMIT
I I hereby affirm that I have a certificate of consent to self insure,
or a certificate'of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.)
Policy O. 3 company "� ' �C'�'�"' FOR APPLICANT TO FILL IN JOB O�/,�►
Certified co is hereby furnished. EACH NO. FEE ADDRESS e6
PY Y New Residential Bldgs.& Pools _
Certified copy is filed with the cou uil g ' spection 1 & 2-Family, Sq.Ft.lair �� $ I = $ LOCALITY f C f
department. Multi-family Sq.Ft. -NEAREST
'CROSS ST.' G h�
Date Applicant Residential Swimming Pools X OWNER OR
FIRM NAME
CERT FICATE OF EXEMPTION FROM O fRS' Outlets:Rec Light Sw.' MAIL
COMPENSATION INSURANCE 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 Te No.
- • PLAN CHECK
I certify that in the performance of the work for which this permit 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
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE, TO APPLICANT: If, after making this Certificate of APPLICANT
(� v
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Cade, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESSS e
provisions or this permit shall"be deemed revoked. Top — FAU _ W.H. c
CITY 0Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
.Ir hereby affirm that I am licensed under provisions of Chapter 9LICEN E OR
Disp. Room Air Cond. Class:
(commencing with Section 7000) of Division 3 of the,Business and REG.NUMBE
Professions Code,and my license is in.full force and effect.' Power Apparatus& Large Appliances DISTRICT NO. /)i r
PROCESS YgSize& Type HP,KW,KVA,or KVAR � O Q
License Number (1.3 Lic.Class G= d Up to 1 Incl FINAL
Over 1 to 10 Incl. DATE AT ION'
Q
Cohtracto ate Over 10 to 50 Incl. FIN V
❑ 1 am exempt under Sec. Over 50 to 100 Inc. B
B.&P.C.for this reason Over 100 fA
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
EJ Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances r.
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law t
for the.following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits y L 7
Code):
❑ Misc.Conduits&Conductors ITEMIS
I,as owner of the property,will do the work and the structure
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Compee e)
Fee Schedule)
_
is not intended or offered for sale (Section 7044, Business Other(See-
and Professions Code). TOTAL
#AL
CONSTRUCTION LENDING AGENCY
I 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) 2, CHANGE. fI€
Civ.C.)._
PLAN CHECKING FEE g t_lj�#I^311 I3} 1/27/259
Lender's Name �y ��
PERMIT ISSUING FEE ' ( 3( �s
Lender's Address h {
t
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State Aews regulating Electrical wiring, and hereby authorize
represent i of is C my to enter on the above-mentioned
property o in c ion poses.
SEE REVERSE FOR EXPLANATORY LANGUAGE ,.
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S' nat e i ee e