HomeMy Public PortalAbout10638 OLIVE ST_Electrical__ I
WORKERS'COMPENSATION DECLARATION vf; 76-6t0/6t APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I I� a certificate of consent to self insure, CE-606G o6G
or a cortificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof SAC.3BOO ab.C.)
Policy N u Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furrnshad• New Illesidential Bldgs.&Pools EACH NO. FEE ADDRESS i
Certified copy is filed with the county budding inspection 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY ej,f le C z�L
NEAREST Q
department. A Multi-family Sq.Ft. CROSS ST 04
Date oApplicant��� �G �G Residential Swimming Pools OWNER OR
ep
FIRM NAME \
CERTIFICATE OF EXEMPTION FRO ORKERS' Outlets:Rec_Light Sw. —- MAIL
COMPENSATION INSURANCE — ADDRESS
(This section need not be completed If the work involved by the First 20 C Ll Tel.No.
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit APPLICANT K
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 CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT �✓, ��L--
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 -V-79 y,
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY q/,% ,�d Tel.No. VZ
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE 75 Class.
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSE Y
Power Apparatus&Large Appliances
`� 9-- ti Size&Type HP,KW,KVA,or KVAR Q
License Num r Z� Li lass —� Up to 1 Incl. FINAL V
-rte Over 1 to 10 Incl. o DATE
Contracto 71 ddd��� ��"ddd""" VALIDATION
Over 10 to 50 Incl. FINAL 0
ElI am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100
Services,Swbd.,MCC&Panelboards
Date: '0-200 Amp.Under 600 V r
Signature 201 - 1000 Amp.Under 600 V
❑
Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Signith One Branch Circuit _
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits �vi L•�air
for the following reason(Section 7031.5,Business and Professions
Code): '
v�Jf
❑ I,as owner of the property,
roert ,will do the work and the structure Misc.lConduits&Conductors
is not intended orof offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ s`�E�
and Professions Code). ® TO T AL 49 .00
CONSTRUCTION LENDING AGENCY r'0r'` G-'
I hereby affirm that there is a construction lending agency for the 1'
Performance of the work for which this permit Is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE eLU
Civ.C)
PLAN CHECKING FEE
Lenders Name I I�Iif�)-i{�f I i 5/16/9"1 L
PERMIT ISSUING FEE
Lenders Address i 13707 1 Ali iG o 56
I certify that I have read this application and state that the above TOTAL FEE JV7. 400
information is correct.I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
representatives of this Cou ty toe r upon the above-mentioned
pro for inspection pur ses.
® I SEE REVERSE FOR EXPLANATORY LANGUAGE
,919matUre of Permitte Date