HomeMy Public PortalAbout9590 LOWER AZUSA RD_Electrical__ riWORKERS COMPENSATION DECLARATION 76A663 10/81
I hereby ��rm.'�fiat I have a certificate of consent to self insure CE 806G APPLICATION FOR ELECTRICAL PERMIT
or a ce rte of Workers Compensation Insurance or a Certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
cop!�ec 3800 Lab C)
Pohcy NO Company FOR APPLICANT TO FILL IN JOB9a L dr��2
E] Certifiedcopy is hereby furnished New Residential Bldgs &Pools EACH NO FEE ADDRESS
❑ Certified copy is filed with the county budding inspection 1 & 2 Family Sq Ft $ _ $ LOCALITY
department Multi family Sq Ft NEAREST T ^,, C / /
Residential Swimming Pools OWNER OR /-I G
pate Applicant t�dr L t j fl d (/—'
CERTIFICATE OF EXEMPTION FROM WORKERS "L MAIFIRM NAME /� 7 t' ��
COMPENSATION INSURANCE Outlets Rec Light_ t 2 ADDRESS % S 9 0 L 0 w� /'Zt/S
(This section need not be completed if the work Involved by the First 20 CITY p
permit Is for one hundred dollars($100)or less► Total No Additional C'J"t Tel No%6 6
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
is issued I shall not employ any person in any manner as to
become subject to the Workers Compensation Laws lighting Fixtures First 20 ADDRESS
/ �7 � Additional
Date 10—Za—�7Applica Total No CITY Tel No
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this CeITRZate of APPLICANT tTds`C
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _
provisions of the Labor Code you must forthwith comply with such Oven — Dryer _ W M _ ADDRESS 5 O G O^/Jri,4e /rd
LV
provisions or this permit shall be deemed revoked Top — FAU WH _
LICENSED CONTRACTORS DECLARATION Hood .- Fan J__ Other_ O> CITY C�Y 11 Tel No��9�
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Au Cond a uCENSE 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 Power Apparatus&Large Appliances DISTRICT N / PROCESS D BY
Size&Type HP KW KVA or KVAR (JX
License Number Lic Class Up to 1 Incl FINAL
Over i to 10 Incl DAT
Contractor Date �/ AID TIO O
13Over 10 to 50 Incl FI
I am exempt under Sec Over 50 to 100 Inc A 8 1 Q b A 0
W
BAPC for this reason Over 100 # e e e e ♦2 N
Date Services Swbd MCC&Panelboards r ► + e e a 5 O Z
0 200 Amp Under 600 V / r";
Signature 201 1000 Amp Under 600 V e e e Q Q 5 O 0
❑ Exemption for Reg MaOver 1000 Amp or Over 600 V
mt Elect I 1 Q26-87
SINGLE FAMILY Temp Power Pofe& Appurtenagces
HOME OWNER BUILDER DECLARATION Sign with One BrAph Circuit
1 hereby affirm that I am exempt from the Contractors License Law
for the following reason(Section 70316 Business and Professions Additional Sign Branch Cirdnts
Code)
511,1 as owner of the property will do the work and the structure Misc Conduits&Conductors
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) _ pool,
Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total)
Civ C)
PLAN CHECKING FEE
Lenders Name PERMIT ISSUING FEE
Lender S Address
I certify that I have read this application and state that the above TOTAL FEL s�
information is correct I agree to comply with all County ordinances
and State laws regulating Electrical wiring and hereby authorize
representatives of this County t enter upon the above mentioned
property for msp tion purpose ''J SEE REVERSE FOR EXPLANATORY LANGUAGE
SI ature Permittee Date