HomeMy Public PortalAbout6223 OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION I 776A663 DPW 3/87 APPLICATION FOR ELiCTRICAL PERMIT
I hereby affirA. that I`�iave a certificate of consent to self CE-806G
or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS LI
or a certified copy thereof(Sec. 3800, Lab. C.) i
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE 1ADDRESS
49.2 3
Certified co is filed with the count buildinginspec- 1 &2-Family, S Ft. $ — $ LOCALITY
copy y p I 9 NEAREST
tion department. I Multi-familyS Ft.
Residential Swimming Pools TOWN R CROSS OR d p
Date Applicant (FIRM NAME LIA GK ♦ f Fes.
CERTIFICATE OF EXEMPTION FROM WORKERS' i Outlets: Rec Light Sw._ AIL
(ADDRESS C� ACOMPENSATION INSURANCE First 20
oie(This section need not be completed if the work involved by Total No. Additional iCIT Tel. No S'�'
the permit is for one hundred dollars($100)or loss.) i PLAN CHEC
I certify that in the performance of the work for which this j iAPPUCANT
permit is issued, I shall not employ any person in any manner I Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensati Laws.
Additional
Date Applican Total No. CITY Tel
NOTICE TO APPLICANT: If, after eking this Cer icate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should becom subject to the Workers' Range— Heater—D.W. _ APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CITY v Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business I Power Apparatus&Large Appliances DISTRICT NO. PROCES BY d
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR [or O
License Number Lic. Class Up to 1 Incl. FINAL 0
Over 1 to 10 Incl. DATE e. � �/� VALI TION O
Contractor Date i Over 10 to 50 Incl. �/ U
❑ FINA
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.BP.C. for this reason Over 100 d
Date: Services, Swbd., MCC&Panelboards /} Z
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V t
Over 1000 Amp. or Over 600 V Y
Exemption for Reg. Maint. Elect. y o c
SINGLE FAMILY I Temp. Power Pole&Appurtenances o
C
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit n u
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits G 6 1
Professions Code):
I, as owner of the property, will do the work and the I Misc. Conduits 8 Conductors
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ,
Business and Professions Code).
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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE �S
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
her by out orize repres atives of this County to enter upon
th abov a tin7edKperty fo 'nspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gna ure of Per Date ®'