HomeMy Public PortalAbout9344 LOWER AZUSA RD_Electrical__ 'WORKERS'COMPENSATION DECLARATION ' 76A 63 10161
I fiery`": affirm that I.have a certificate of consent'to self insure, cE- 0se APPLICATION FOR ELECTRICAL PERMIT
ar a nneate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES i BUILDING AND SAFETY LI
eof7inareof(Sec.3800,Lab.C.) 1 n
Policy No: Company FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. N.w Residential Bldgs.&.Pools EACH NO. FEE
$ — .$ jLOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. — EAREST
department, Multi-family Sq.Ft. CROSS.3T: CI N
Date _Applicant Residential Swimming Pools ,OWNER OR
I FIRM NAME e N s To W
CERTIFICATE OF EXEMPTION FROM WORKERS' O'tlets:Rec—Light_Sw. iMAIL
COMPENSATION INSURANCE (ADDRESS . + 5 t—o vi c� �I Z_us W Pel
(This section need not be completed.If the work involved by the First'20
permit is for one hundred dollars($100)or less.) Total No. Additional ,CITY Tel.No. '�9,_,,?Y�
s
I.oertif that in the performance of the work for.which this permit IIPLAN CHECK
y P { APPLICANT
is!issued, I shall not employ any person in any manner so as to
become subject to the.WorkersCompensation L ws. Lighting Fixtures First 20 - `ADDRESS.
Additional
Total No: iICITY Tel.No.
Date Applicant
—
F11 d Appliances Not Over 1 HP ''PERMIT
NOTICE TO APPLICANT: If, after making this Certificate •of:
Range— Heater_ D.W. i+APPLICANT IAF/r![C/BC &17—.za/o
Exemption,you should become subject to the Workers'Compens..ation I � p
provisions of the Labor Code,you,must forthwith comply with such Oven Dryer_ W.M._. !ADDRESS
3f( (dN,p�7 _LtS /�fi�
provisions or this permit shall'be deemed revoked. Top •_ FAU _ W.H.
LICENSED CONTRACTORS DECLARATION i FijCITY Tel.NO.
H �UD
ood — an _ Other_
I hereby affirm that I,arn. licensed under provisions of Chapter 9 Disp. — 'Room Air Cond. IIREG Class.
LJCENSE OR
(commencing with Section 700.0)of Division 3 of the Business.and ;NUMBER
Professions Code,and my license is in full force and effect.. DISTRICT NO. P ED.
P r Apparatus&Large Appliances
I Size&Type HP,KW,KVA,or KVAR
Q
License Number,- _ Lic..Class Up to. 1 Incl,
Over 1 to 10 Incl. ATE n.� (� VALIDATION.
Contractor Date Over 10 to 50 Incl. J 1�
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. IBY
B.&P.C...for this reason Over 100
S rvices;Swbd.,.MCC&Panelboards
Dater 0-200 600
'Signature 201 - 1000 Amp:Under 600 V l
❑ '; Over 1000 Amp.or Over.600 V I
Exemption for Reg:Maint:'Elect.
SINGLE FAMILY Tgmp.Power Pole.$Appurtenances'
HOME OWNER.BUILDER DECLARATIONSign with One Branch Circuit
I hereby affirm that I am ex..empt from the Contractor's License Law I a
for the follbW!hg reason(Section.T03A.5,Business and Professions It
Sign Branch Circuits ACC. ■a
Code): 33,07 31.0D*
I,as owner of the property,will do the work and the structure sc:Conduits&Conductors 1 ITEMS
is not intended or offered for sale (Section 7044, Business. Other(See Complete Fee Schedule......_
and Professions Code). i , TOTAL 31.00
'CONSTRUCTION LENDING AGENCY0
I hereby affirm that there is a construction.lending agency fbr the I � .1■00
performance of the.work for which this permit is issued(Sec.309.7, PERMIT FEE (Sub-Total) CHMG}E. ,. t
Civ.C.)'.
PI AN CHECKING FEE
Lender's Name I, 0000-0001 55/30/90
PERMIT ISSUING FEE13
Lender's Address. I• . 0995 1 AM: 90-21
1 certify that I have read this application and state that:the.above TOTAL FEE 311 D • :
information is correct.I agree to comply with all County ordinances i w
and State laws regulating Electrical: wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
propert r' ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature r as Date -