HomeMy Public PortalAbout10553 OLIVE ST_Electrical__ 1
e .WORKERS'COMPENSATION DECLARATION 66 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby_affirm that I have a certificate of consent to self CE-606G
insure;or'S c'eriificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a ce' Jfied copy thereof(Sec. 3800, Lab. C..)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
Certified co is filed with the count building p 1 &2-Family, S Ft. $ _ $ LOCALITY
copy ' y gins ec- Y q•
tion department. Multi-family Sq. Ft. NEAREST r
CROSS 5T.
Residential Swimming Pools
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
This section need not be completed If the work involved b First 20
the
the Is for one hundred dollars($100)or fess.) Y Total No. Additional CITY Tel. No�
PLA
1 certify that in the performance of the work for which this APPLICANTK
permit is issued,I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date Applicant Q CITY
r Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, afteoqA
r aking th' Certificate of APPLICANT Xd
Exemption, you should becosubject t the Workers' Range_ Heater—D.W. —
Compensation provisions of the Labor Code, ou must forth- Oven —Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. — CITY Tel. No.
deemed revoked. Hood _ Fan _Other_
LICENSED CONTRACTORS DECLARATION /g ICENSE OR
I hereby affirm that I am Iicensed under provisions of Chapter 9 Disp. Room Air Cond. Z- REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business E E DISTRICT NO. PROLBY
y
and Professions Code,and m license is in full force and effect. Power Apparatus 8 Large Appliances
Size&Type HP, KW, KVA, or KVAR
License Number Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE r VALI ION
Contractor Dote Over 10 to 50 Incl. u
D ::]FINA
I am exempt under Sec. Over 50 to 100 Inc. F W
CL
B.&P.C. for this reason Over 100
Services, Swbd., MCC&Ponelboords ® 2 6 9 C A
Date: 0 -200 Amp. Under 600 V
g�
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V o 0 0 =
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances 1 -3-85
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License additional Sign Branch Circuits
Law fo he following reason (Section 7031.5, Business and
Prof,qXions Code):
I, as owner of the property, will do the work and the M;sc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY i
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) p2
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address 1
I certify that I have read this application and state that the J,TOTAL FEE
above 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 insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_I L i
n ture of Pe it a Date