HomeMy Public PortalAbout9508 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION CE-8066
f, 10,81 APPLICATION FOR ELECTRICAL PERMIT
I here�;affirm that I have a certificate of consent to self CE-806
t"r:Fnsure,�br a certificate of Workers'Compensation Insuranc COUNTY OF LOS ANGELES I BUILDING AND SAFETY
or apirti 'fled•copy thereof(Sec. 3800, Lab. C.)
1`0114
4 No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
Certified copy is filed with.the county building inspe. 1 A 2-Family, q S Ft. $ — $ I LOCALITY X10,dr '� 12,10
'NEAREST
tion departments Multi-family Sq. Ft. CROSS ST.
Date + Applicant Residential Swimming Pools OWNER OR f'i1112�
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._
MAIL
COMPENSATION INSURANCE I' ADDRESS � s�t
(This section need not be completed If the work Involved bFirst 20y Total No. Additional I CITY Tel. No. ?,
the permit is for one hundred.dollars($100)or less.)
I certifythat in the erformance of the work for which this PLAN CHECK.
P i 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 I 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 19
Exemption; you should become subject to the Workers' Range_ Heater_D.W. APPLICANT J��� �
Compensation provisions of the.Labor Code, you must forth- Oven —Dryer _W.M.— ADDRESS 'Z-3 ll A, j34 Id1We-�;-
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood —.Fan _Other_ CITY�C Tel. No.227 Oc�
LICENSED CONTRACTORS DECLARATION LICENSE OR p�
Disp. _ Room Air Cond. REG.
I hereby affirm that I am.licensed under provisions of Chapter 9
NUMBER Cp / Class.
(commencing with Section 7000)of.Division 3 of the Business DISTRICT NO. PROCS BY
and Professions.Code,and my license is in full force and effect.
Power Apparatus 8 Large Appliances .I y.
Size&Type HP, KW, KVA, or KVAR V t a.® 0
License Number Lic. Class Up to 1 Incl. I FINAL V
Over 1 to,10 incl. l DATE. f VALI ION
Contractor. Date._ Over 10 to 50 Incl. V
❑ FINAL/
I am exempt under Sec. Over 50 to 100 Inc. 1 BY W
B.&P.C. for this reason I Over 100
Date:
Services, S.wbd., MCC&Panelboards / j1
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. 2 4 9 A
SINGLE FAMILY Temp. Power Pole&Appurtenances # 0 0 0 0 0 2
HOME OWNER-BUILDER DECLARATION !
Sign with One Branch Circuit I 0 0 2 5 Jr
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason. (Section 7031.5, Business and o 0 0 2 Jr 5
Professions Code):
05
❑ I Misc..Conduits&Conductors
• I, as.owner of the property, will do the work and the o7. 1 6—$5
structure is not intended or offered for.sale .(Section Other(See Complete Fee Schedule)_
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I ,
I hereby affirm that there is a constructlon lending agency fdr i
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) IS
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name c
' PERMIT ISSUING FEE `Q S
Lender's Address �
I certify that I have.read this application and state that the TOTAL FEE Z V.
above information is correct. I agree to comply with all County
ordinances and-State laws regulating Electrical wiring, and
hereby authorize rep sentatives of this County to enter upon
the above-mentio d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ig ture of Permittee Date
i