HomeMy Public PortalAbout6644 OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A66310/61
Eby affirm that I have a certificate of consent to self insure,
,5,Frtificate of••Workers'Compensation Insurance, or a.certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
u� L+opy toereof(Sea 3800,Lab.C.)
Policy Na_Company FOR APPLICANT TO FILL IN JOB
ADDRESS nat )/
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO.. FEE
Certified copy is filed with the county building inspection
1 &2-Family,Sq.Ft $ — $ LOCALITY
department. Multi-family.Sq.Ft. — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' ' MAIL
COMPENSATION INSURANCE Outlets:Recl• Light 't 2 ! ADDRESS
cc���� First 20 `7� ''
(This'sectlon need not be completed if the work involved by the Total No. 7 Additional y� d.CITY 7 Tel.Nb.
permit is for°one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit °r A LAN
K
is issued, I shall not employ arty person in any manner so as to
become subject to the Workers'Compensation ws. �! Lighting Fixtures First 20 3 ``� ADDRESS
-2.116/51 Total No. Additional CITY Tel.No. ,
. Date .. Applicant Fixed Appliances Not Over 1 HP, PERMIT
NOT CE TO APPLIC T: If, making this Certificate .APPLICANT "A l ^ C®
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
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provisions or this permit shall be deemed revoked. Top _ FAU W.H. .,9
LICENSED CONTRACTORS DECLARATION Hood — :Fan Other_
CITY U t Te ,�$6• 09
I hereby affirm .that I am licensed. under provisions of Chapter 9 ( LICENSE OR
(commencing with Section 7000)of Division 3 of the Business.and Disp. — Room Air CI REG.NUMBER Q Clas$e0-10
Professions Code,and my License is.in full force and effect. I DISTRICT NO. PR D BY
I. Power Apparatus&Large'Appliances , O�• MR
//•��� /y /��� Size&Type HP,KW KVA,or KVAR t Q
License Number!440�� ! Lic.Class Std Up to 1 Incl. %! FINAL 8
g Over 1 to 10 Incl. DATE ` _C�
Contractor A/.7 q �o� VALIDATION
H/T: /�r ��iQ/(N.nate ��7 0
Over 10 to 50 Incl. FINA
I'am exempt under Sec. r Over 50 to 100 Inc. BY over 100 W
W
B.&P:C..for this reason
Services,Swbd.,MCC&Panelboards Z
Date: 0-200 Amp.Under'600 V
j( Signature 201 - 1000 Amp.Under 600 V
( Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.Maint.Elect
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOMEOWNER-BUILDER DECLARATION -Sign with.One.Branch Circuit
hereby affirm that'!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
is not intended or offered for-sale (Section 7044; Business Other(See Complete Fee Schedule) ► 8 6 9�.
and Professions Code). # 0 0 0 0 0
CONSTRUCTIbN LENDING AGENCY 1,o - 4675
1 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) 0 0 04675'06
Civ.C.). 1230-87
PLAN CHECKING FEE
Lender's Name • '
PERMIT ISSUING FEE D
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 i spection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i to f i tee Date