HomeMy Public PortalAbout9927 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION . A80 10/81 APPLICATION FOR ELECTRICAL PERMIT {�
I herebJ affirm tli�t I have a certificate of consent to self insure, CE
CE'8o6(3G �J
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof I Sec.3800,Lab.C.) � `
S per' '�Q C FOR APPLICANT TO FILL IN JOB
Policy No. any .ADDRESS 2, �.--
❑ Cert'ied copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. EE
1 & 2-Family,Sq.Ft. $ — $ LOCALITY t
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant 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 gpPPLICAgNT K
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
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HIPPERMIT �
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ DW _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS Z Z
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
S_ 6�
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9Disp. — Room Air Cond. LICENSE OR
. T—
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER J
Class
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. ESS D ���,,,''''''
Size& Type HP,KW,KVA,or KVAR ��
License Number Lic.Class ��� Up to 1 Incl. FINAL J
�_� � T' k Over 1 to 101ncl. DATE IX
Contractor 3:�tT\l"�_a�Date 8 �b� VALIDATION 0
❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY
BAP.C. for this reason Over 100
Services,Swbd.,MCC&Panelboards N
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. 2
'SINGLE FAMILY Temp.Power Pole&Appurtenances 1i4T�T
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit AC
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits 3307 U74.15
for the following reason(Section 7031.5,Business and Professions
Cade): 1 ITEMS
❑ Misc.Conduits& Conductors
I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) TOTAL 124. 15
is not intended or offered for sale (Section 7044, Business
and Professions Code). poll. OECt 124.15
CONSTRUCTION LENDING AGENCY .00
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 1 8/13/90
Lender's Name 2364 1 AM10:4b
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
prop y for inspec�pa.l�► ores. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signat#of Permittee Date ,,ter-r..—7