HomeMy Public PortalAbout9556 OLIVE ST_Electrical__ WORKERS'COMPE..NSATIONDECLARATION CE-8 (280) APPLICATION FOR ELECTRICAL PERMIT
I -hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
1 Policy No., Company, EACH NO, FEE ADDRESS c 1 p L SE
New Residential Bldgs.&Pools
0 Certified copy is her furbished. 1 &2-Famil%Sq. Ft._� $ — $ LOCALITY
rJMulti-family Sq. Ft. — NEARES.T
Certified copy Is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR
` FIRM NAME
Date Applicant Outlets: Rec._Light Sw. MAIL
First 20 ADDRESS
CERTIFIC,ATE OF"EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. }
COMPENSATION INSURANCE PLAN CHECK d
APPLICANT U
(This section need not be completed if the work involved Lighting Fixtures First 20
by the pernut is for one hundred dollars ($100) or less.) Additional by W
Total No.
I certify that in .the performance bf the work for which•this ixed Appliances Not Over 1 HP CITY Tel No. (—
permit is issued, I shall not employ any p rson ' manner PERMIT
.so as to become'subjec ake ' ti Range_Heater_D.W:_ APPLICANT d
GC/
N
Oven _ Dryer_W.M._ ADDRESS +
Date e�pplican Top _ FAU _W.H.._
Hood — Fan ._Other_ CITY Tel No.
NOTICE TO APPLICANT:If, after making this Certificate of Disp. _Room Air Cond._ LICENSE ORf�
Exemption, you should become subject to the Workers, REG.NUMBE Class
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO�r PROC D BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl.
• FINAL
Over 1 10 Incl. DATE
Over 10
LICENSED CONTRACTORS DECLARATION to
to 50 Incl. ! VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to•100 Inc. FINAL q �
9 (commencing with Section 7000).of Division 3 of the Busi• Over 100 BY
ness and Professions..Code, and my license is in full force and �}
effect. Services
Lic nse •uinb c.Class G 6200 Amp.Under 600+V �•
201-1000 Amp.Under 600 V
Over 1 O00 Amp.or Over 600'V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
Sign with One Branch Circuit
I hereby affirm that I am exempt* from the Contractor's Additional Sign Branch Circuits I
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): +' -• o o. - 2
'
Misc.Conduits&Conductors
I, as owner .of the property, will do the work and the Other(See Complete Fee Schedule)— _
structure is not .intended or offered for sale (Section c c � c
;��
7044,Business and Professions Code). rj
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending.agency'
for the performance of the work for Lvhich this permit is PERMIT FEE (Sub-Total)
issued(Sec.3097,Civ.C.).
'Lender's-Name. PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the 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.pro rt r r inspection purposes. SEE•REVERSE FOR EXPLANATORY LANGUAGE
Signature.o rPermittee Date