HomeMy Public PortalAbout5761 OAK AVE_Electrical__ WWRKERS COMPENSATION DECLARATION CE 76A663
10'81APPLICATION FOR ELECTRICAL PERMIT
ffirm that I have a certificate of consent to self insure
ora certificate of Workers Compensation Insurance or a certified COUNTY OF WS ANGELES BUILDING AND SAFETY
copy thereof J.Sec 3800 Lab C) flC)�1T �1/ D
Policy No Company �`�'^� • FOR APPLICANT TO FILL IN QPB
ADDRESS iv ✓�--
❑ Certified copy,s hereby furnished New Residential Bldgs &Pools EACH NO FEE LOCALITY
❑ rf,e with the county budding inspection 1 &2 Family Sq Ft $ r $
Multi family Sq Ft , NEAREST
Residential Swimming Pools CROSS 3T
p ER OR
phcent Pm RM NAME
CERTIFICATE EXEMPTION FROM WORKERS �J +� MAL
COMPENSATION INSURANCE Outlets Reo Light T t 2 �i / �.r ADDRESS 1�2�
(Th)s section need not be completed it the work Involved by the 2 Fust 20 `
permit Is for one hundred dollars($100)or less) t
Total No Additional CITY Tel No
H15f
1 certify that in the performance of the work for which this permit - PLAN
is issued 1 shall not employ any person in any manner so as to A��
become subject to the Workers Compensation Laws Lighting Fixtures First 20IN
ADDRESS
t i Total No Additional CITY Tel No
Date Applicant Fixed Appliances of Over 1 HP
NOTICE TO APPLICANT If after making this Certificate of ! PLIC
Exemption you should become subject to the Workers Compensation Range Heater t DW -APPLICANT D
provisions of,the Labor Code you must forthwith comply with such Oven Dryer W M ADDRESS Ag�rw An,��
provisions or this permit shall be deemed revoked Top FAU WH _
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other CITY Tel No
I hereby,affirm that I am licensed under provisions of Chapter 9 D,sp — Room Air Cond LICENSEClass
(commencing with Section 7000)of Division 3 of the Business and REG NUMBER
Professions Code and my license a3 in full force and effect Power Apparatus&Large Appliances DISTRICT OES&ED EDL
��71
/ 1 Size&Type HP KW KVA or KVAR Q—
Lroense NumberT�T�`u'�'� LIc Class y Up to 1 Incl FINAL v
Contractor r -Twk)S�� to Over 1 to 10 Incl DAA V VALIDATION D'
❑ Over 10 to 50 Incl FI
I am exempt under Sec Over 50 to 100 Inc 2
B&PC for this reason Over 100 Ae f T T N
Services SwbA MCC&Panelboards ► � 49.E
Date 0 200 Amp Under 600 V '+ "i
Signature i!W201 1000 Amp Under 600 V 1 ITEC
Over 1000 Amp or Over B00 V
❑ Exemption for Reg Mamt Elect TI ITAL 4 9 o 25
SINGLE FAMILY Temp Power Pole&Appurtenances CHELY 49 25
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits
CHANGE [Irl
for the following reason(Section 70315 Business and Professions
Code) r
❑ Misc Conduits&Conductors � CCO-00Q1 4/ 4/89 I as owner of the property will do the work and the structure r
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)
and Professions Code) pop- 7729 1 AM 2
0 3
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 y
PERMIT ISSUING FEE _Jig
Lenders Address
I certify that I have read this application and state that the above TOTAL FEE Al
information is correct I agree to comply with all County ordinances
and State laws regulating Electncal wrong and hereby authorize
representatives of this County to enter upon the above mentioned
property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
G✓ J C___ 0141'e,
Signature of Permittee 0ate