HomeMy Public PortalAbout9921 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION CE 806G '0'81 APPLICATION FOR ELECTRICAL PERMIT L�1'
I hefebT affirm that I have a certificate of consent to self insure, 1 )
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ILJI
copy there o (Sec.38 O,Lab.C.)
&29
Policy No. 0SLpany FOR APPLICANT TO FILL IN. JOB
ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.& ols EACH NO. FEE
1 & $ LO
Certified copy is filed with the county building inspection 2-Family,Sq.Ft. CALITY
2 $ —
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light —Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
(This section need.not be completed If the work Involved by the First 20
Tota . Additional CITY Tel.No.
Total No
permit Is for one hundred dollars($100)or less.) 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
Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making. this Certificate of APPLICANT GWL�
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS Otollif
provisions or this permit shall be deemed revoked. Top FAU _ W.H. CITY T.I.No. Z
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. ROOM Air Cond. REG.NUMBER r Claw
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO. PR SED BY
Power Apparatus&Large Appliances
-�{-/�'�3 Size&Type HP,KW,KVA,or KVAR
License Number , `J`� lac.Class Up to 1 Incl FINALDATE ��
rac �� Over 1 to 10 Incl.
Contractor e VALIDATION
DatIO-
❑ Over 10 to 50 Incl. FINAL
p/i U
I am exempt under Sec. Over 50 to 100 Inc. BY
gy
B.&P.C.for this reason Over 100
Services,Swbd.,MCC&Panelboards Z
Z
Date: 0-200 Amp.Under 600 V r"
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V '
Exemption for Reg.Maint.Elect.
r
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 3307 12.4.1
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,Business and Professions - Additional Sign Branch Circuits 1 ITEM..
Code):
TOTAL 124 . 15
❑ I,as owner of the property,will do the work and the structure
Misc.Conduits&Conductors .1
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
and Professions Code). ► CHANGE
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) 0000--O01 8/13/9O
Civ.C.).
,PLAN CHECKING FEE - 2367 1- AM10:48
Lender's Name
PERMIT ISSUING FEE
Lender's Address /
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 laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes.
DSEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permittee Date