HomeMy Public PortalAbout6537 OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION -663 10/81 AP P U CATI®IN FOR ELECTRICAL PERMIT
I hereby affirm Wait. CE-806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING.ANaD SAFETY
copy thereof(Sec.3800;Lab.C.)
Policy No.: Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. EACH NO. .FEE ADDRESS
. New Residential Bldgs.&Pools , LOCALITY t
❑ Certified copy is filed with the county building,inspection 1 &2-Family,Sq.Ft. $ _ $
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date -Applicant Residential Swimming PoolsM OWNER OR f \
Outlets:RecN_Light Sw. FIRNAME �
CERTIFICATE.OF EXEMPTION FROM WORKERS' ', MPdI
CFirst 20OMPENSATION INSURANCE Z/s3 1�� 60 ADDRESS
(This section need not be completed if the work involved by the Total No. Additional CIT . \ Tel.No.
permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that'in the performance of the work for which this permit APPLICANT ,
is issued, I.shall not employ any person in any manner so as
become subject to the Workers'Comp sation L Lighting Fixtures t First 20 ADDRESS
v / Total No. .aditional CITY Tel.No.
Date °� Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTI E TO APPLICANT:..If, a r making th Certificate of I APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the•Labor Code,you must forthwith comply with such Oven — Dryer_ W.M._ ADDRESS ` gdflaww
provisions or this permit.,shall be deemed revoked. Top FAU W.H. e'
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_. i CITY' ' Tel.No.
— .
I hereby affirm that I am licensed.under proy'isions of Chapter 9 LICENSE OR
Disp. — Room'Air Cond. REG.NUMBER 74 Class. m
(commencing with'Section'7000)of Division 3 of the Business and
Professions Code,and my license,is in full force and effect. power Apparatus&Large Appliances DISTRICT NO. y PRO SSEED BY
.0 A /' Size&Type HP,KW,KVA,or KVAR s Q
License Number Lic.Class (/ Up to 1 Incl. FINAL 8
a ®N Over 1 to 10 Incl. DATE e G (�
Contractor Date V f Z/ VALIDATION
Over 10 to 50 Incl., FINAL
E] I am exempt under Sec. Over 50 to 100 Inc. BY W
BAP.C.for%is reason (� Over 100 N'
Am Ty® D . 1 Services,Swbd.,MCC&Panelboards' U)
0-200 Amp.Under 600 V
Signat 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 DECLARATION Sign with One Branch Circuit z.
I hereby affirm that I am exempt from the Contractor's License Law
Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions _
Code):.
Misc.Conduits&Conductors -- � -•
❑ I,as owner of the property,will do the work and the structure i L�10
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). IQ PAL 65a
CONSTRUCTION LENDING AGENCY Cf j o_2
•I hereby affirm that there is a construction lending agency for the ;-t (1
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) t E ANGE "'')"
Civ.C.).
PLAN CHECKING FEE
Lender's Name rI_I ;0-00 01 li/12 1 .L
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date