HomeMy Public PortalAbout9095 OLIVE ST_Electrical__ WORKERS'COMPENSATION DECLARATION • `,' 76663 CEA-806G '0'81 APPLICATION FOR ELECTRICAL. PERMIT
(�ereby'afitrm that I have a.certificate of consent to self insure;.
,r> orftificate of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES � BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.j -� -
Policy.No. Company FOR APPLICANT TO FILL.IN JOB O l O v
❑ 'Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS J
❑ I 1 8 2-Family,Sq.Ft. $ _ $ LOCALITY
Certified copy is Filed with the county building inspection, NEAREST
department. Multi-family Sq.Ft.
CROSS ST.
Date ).', Residential.Swimming Pools OWNER OR
Applicant 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 by theFirst 20
permit Is for one hundred dollars($100)or less.) r
Total No. -Additional , CITY Tel.No.
I certify that in the performance of the work for which this permit PALPAPNUCANT K
is issued, I shall not employ any'person in any mannerioas to,
become subject to the Workers`Compensat' - Lighting Fixtures First 20 ADDRESS a�07 /� L9S ✓���"�$
Total No. Additional CITY ` Tel.No. ,?gCI�
-/D.-� rc9 GI
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If; after making. this Certificate of APPLICANT /jll "moi
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
provisions or this permit shall be deemed revoked. Top FAU _ W.H. _ CITY �� Tel.No. � Ga
LICENSED CONTRACTORS DECLARATION Hood — Fan. — Other_
I hereby affirm that I am licensed under'provisions of Chapter 91, �•
Disp. — 'Rbom Air.Gond. LICENSE ORREG.NUMBER �.� 0
(commencing with Section 7000)of Division 3 of the Business and CIe�a
Professions Code,and my license is in full force and effect. DISTRICT.NO. P . CES ED BY
Power Apparatus&Large Appliances d
Size S Type HP,KW,KVA,or KVAR d O
License Number. 3 7 7�71a�� LIP.Class G`D Up to 1 Incl. FINAL V
Contractor D7S�J /C�1� �� Date �6— Over 1 to 10 Incl. DATE .� - VALIDATION p�
Over 10 to 50 Incl. FINA CCC!!!
❑ I..am exempt under See. Over 50 to 100 Inc:
B.&P.C.for this reason Over 100 N
Services,Swbd.,MCC&P.anelboards ! Z
Dater 0-200 Amp Under R^n V . —
Signature 201 - 1000 Amp.Under 600 V k
Over 1000 Amp.or Over 600 V
- ❑ , Exemption for Reg.Maint..Elect. � , ' •
SINGLE FAMILY Temp.Power Pole'8 Appurtenances:
HOME.OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,Business and Professions , Additional Sign Branch Circuits
❑ I.as oMisc.Conduits&Conductorswner of.the:property,will do the work and the structure JJ � -
is not intended or offered for sale (Section 7044,.Business I' Other(See Complete Fee Schedule). a. �'r:.=e _e 50-
and Professions Code).
CONSTRUCTION LENDING AGENCY e t-r 25.5(�
w• ,�.T
I•hereby affirm that there is a construction lending agency for the T
performance of the work for which this permit is issued.(Sec.3097,1 PERMIT FEE (Sub Total)
Civ.C.).
i PLAN CHECKING FEE • f' j���`—i 1101/805Lender's Name 8
. r.•-•,
PERMIT ISSUING FEE U 17 !� ` L A�( ;4c.
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 V'
and State laws regulating Electhcal wiring, and hereby authoriza;.f
representat' of this Cou en r upon the above-mentioned ;
props r' coon p o s
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ure of Permittee Date