HomeMy Public PortalAbout9830 OLIVE ST_Electrical__ }WORKERS'COMPENSATION DECLARATION 76A663 10/81
'I hereby affirm. that I hove a certificate of consent to self CE-&W APPLICATION FOP. ELECTRICAL PERMIT
insure, or a certificate of'Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
-or a certified copy thereof (Sec. 3800, Lab. C.) LI
I
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs. &Pools
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY le
tion department. Multi-family Sq. Ft. — NEAREST
CROSS ST
Date Applicant Residential Swimming Pools OWNER O
CERTIFICATE OF EXEMPTION FROM WORKERS' �' I FIRM NAME / y" S
Outlets: Re Light IL
COMPENSATION INSURANCE Sw ADDRESS v f/ IA-k J 4-
(This section need not be completed if the work involved by First 20 /
the pormit is for one hundred dollars($100)or less.) Total No. Additional I CITY ! Tel. Nor_ r-a Z -
I certify that in the performance of the work for which this PLAN CHECK
permit is issued, I shall not employ an person in any manner APPLICANT
so as to become subject to the W ers'Co�sation L ws_ Lighting Fixtures First 20 ADDRESS
Total No. 7/ Additional
JI
CITY Tel. No.
D.fater �� pplicant �
NOT CE TO APPLICANT: If, after making this rtificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT
Exemption, you should become subject to a Workers' Range_ Heater_D.W. —
Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M.— ADDRESS
with comply with such provisions or this permit shall be I Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
Dis _ Room Air Cond. —
I hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. P ED BY
Power Apparatus&Large Appliances I p
and Professions Code,and my license is in full force and effect. F C)
Size&Type HP, KW, KVA, or KVAR . V U r
License Number Lic. Class Up to 1 Incl. FINAL
DATE:? 7Over 1 to 10 Incl. '�� VALIDATION
Contractor Date Over 10 to 50 Incl. FINA �
W
I am exempt under Sec. Over 50 to 100 Inc. BY f�G 0.
B.&P.C. for this reason Over 100 C. Z
Services, Swbd., MCC&Ponelboards
Date: 0 -200 Amp. Under 600 V
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 Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
V/ `JI, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ® 5 9 0.2 A
7044, Business and Professions Code). # o 0 0 0 0 2
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for ° - 17.25
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ0 0 0 ] G 5
V. C. .
(� -1hyu" PLAN CHECKING FEE 1' 1. 10-86
Lender's Name �,�./�
PERMIT ISSUING FEE ff
Lender's Address
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
t bove-mentioned property fqr inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
oAxo / ..l(1) `�
` Signature of Pe 'tee Date