HomeMy Public PortalAbout5831 OAK AVE_Electrical__ WORKERS COMPENSATION DECLARATION 8 606BO)
3
CE APPLICATION FOR ELECTRICAL PERMIT
CE 8
I hereby affirm that I have a certificate of consent to self ` COUNTY OF LOS ANGELES BUILDING A SAFETY
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL IN JOB S45-113)"
' /�L _
Policy No Company EACH NO FEE ADDRESS S4�/� d1
New Residential Bldgs &Pools i�
' Certified copy is hereby furnished 1&2 Family Sq Ft $ — $ CALITY G
O
Multifamily Sq Ft CROSS ST
Certified copy is filed with the county building inspection Residential Swimming Pools
department OF RM NA E
Date Applicant Outlets Rec_Light Sw MAIL �/
First 20 ADDRESS (/
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No
COMPENSATION INSURANCE }
PLAN CHECK CL
(This section need not be completed if the work involved APPLICANT V
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First io ADDRESS Cc
Total No Additional r
I certify that in the performance of the work for which this CITY Tel No V
permit is issued I shall not employ an person in an manner Fixed Appliances Not Over 1 HP
P P Y Y P Y PERMITiL
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT G7 a
Oven _ Dryer_W M ADDRESS , G40Fu/�/d� Z
Date Applicant Top ' FAU _W H
Hood _ Fan _Other_ CITY �Giii7 Tel No L�J
NOTICE TO APPLICANT If after making this Certificate of Disp — Room Air Cond_ LICENSE OR r I
Exemption you should become subject to the Workers REG NUMBS Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR
deemed revoked
Up to 1 Incl FINAL
Over 1 to 10 Incl DATE VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL _
9 (commencing with Section 7000)of Division 3 of the Busi Over 100 BY
ness and Professions Code and my license is in full force and
effect Services
0 200 Amp Under 600 V
License Number Lic Class � !
201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
r
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
additional Sign Branch Circuits
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code)
Misc Conduits&Conductors -06394A
I as owner of the property will do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section # • • • a • 2
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 2 • • 4 3 1 5
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub Total) a • • 4 3 15 C5
issued(Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 0923-82
Lender s Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County v
ordinances -and State laws regulating Electrical wiring and
hereby autho a representatives o this County to enter upon
th above ione operty f spection purp es
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign u of mi DaX