HomeMy Public PortalAbout9923 LOWER AZUSA RD_Electrical__ • WORKERS'COMPENSATION DECLARATION 78-863 10/81
CE-808G APPLICATION FOR ELECTRICAL PERMIT
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.) � fl
Policy No. Company L{ 0.�4:�.A FOR APPLICANT TO FILL IN JOB r,
❑ rl
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Certified Copy is filed with the county building inspection
1 & 2-Family,Sq.Ft.�2'Z3 $ $ LOCALITY
depart nt. Multi-family Sq.Ft. NEAREST
CROSS
Date Applicant O Residential Swimming Pools OWNER OR
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
permit is for one hundred dollars($100)or less.) .
Total No. .Additional CITY Tel.No.
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in.any manner so as to APPLICANT
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
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT
provisions of the Labor.Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS C 2
provisions,or this permit shall be deemed revoked. Top — FAU _ W.H.
LICENSED CONTRACTORS DECLARATIONHood Fan Other_ CITY feLA(ec Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICrJ�0 ED BY
Power Apparatus&Large Appliances LL-J�
Size&Type HP,KW,KVA,or KVAR ffD 8
License Number Lic.Class �0 Up to 1 Incl. FINAL'
Contractor- f-�l��-- Date Over 1 to 10 Inc[. DATE(`
tVALIDATION
❑ Over 10 to 50 Incl FINAL V
I am exempt under Sec, Over,50 to 100 Inc. BY
B.&P.C.for this reason Over 100
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
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION2
Sign with One Branch Circuit
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 t1�+4T.e
A�/�
Code): -3
174■1`
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors +3A
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ 1 1TEMS
and Professions Code).
TOTAL 124 . 5
CONSTRUCTION LENDING AGENCY r t� ��7L C
I hereby affirm that there is a construction lending agency for the MILK tiT.i•i
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.). cKqu .00
PLAN CHECKING FEE
Lender's Name
PERMIT.ISSUING FEE 13 OD
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE 7366 1 1 '110:47
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 purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
SignatureV Permittee Date