HomeMy Public PortalAbout5024 PAL MAL AVE_Electrical__ WORKERS'COMPENSATION DECLARATION W/81 _ APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate ofVcCE-806G onsent to self CE-806G
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company I FOR APPLICANT TO FILL IN JOB
Certified co s hereby furnished. EACH NO. FEE ADDRESS pL
copy iy New Residential Bldgs. 8 Pools
Certified copy is filed with the county building Inspec- 1 &2-Family, Sq. Ft. $. — $ LOCALITY
tion department. Multi-family Sq. Ft. NEARESTCROSS ST. C �
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME.
CERTIFICATE OF EXEMPTION FROM WORKERS' I L MAIL
COMPENSATION INSURANCE j Outlets: Rec Light Sw._ ADDRESS
completed if the work involved b First
(This section need not be com p Y Total No. Additional CITY Tel. No.
the permit is for one hundred dollars.(5100)or less.) gerem
I certify that in the performance of the work for which this PLAN CHECK
permit is issued, I shall not employ any person in any ma er APPLICANT
so as to become subject to the Worker'Compensation ws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date 3 pelican CITY Tel. No.
Fixed Appliances
NOTICE TO LICANT: If, after making this Certificate of er Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range_ Heater—D.W. APPLICA
i
Compensation provisions of the Labor Code, you must forth- Oven _Dryer W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU W.H. — d�
deemed revoked. CITY Tel. N 73 —4-y
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
Dis _ Room Air Cond. LICENSE OR
p' � Class.C��
I hereby affirm that I am licensed under provisions of Chapter 9 REG.NUMBER .J
(commencing with Section 7000)of Division 3 of the BusinessI DISTRICT NO. PROCE
and Professions Code,and my license is in full force and effect. power Apparatus&Large Appliances U�
7fi i Size&Type HP, KW, KVA, or KVAR
License Number ✓v �Z Lic. Class IC Up to I Incl. FINAL
] v09
Contract Date di Over 1 to 10 Incl. DATE �t� f F`I .,J VALIDATION
Over 10 to 50 Incl. �
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY �1— e� 51161
B.&P.C. for this reason Over 100
Services, MCC 8 Panelboards � ,
0 -2000 Amp. Under 600 V
Date:
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 a u a o
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits , r
Law for the following reason (Section 7031.5, Business and , „ i,c f
Professions Code):
❑ I, 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)—
7044, Business and Professions Code). ► l "fir "G . ,
CONSTRUCTION LENDING AGENCY
1 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) vs(
(Sec. 3097, Civ. C.). ID / r ;/q PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE n t�l
Lender's Address @ Y
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 ` ���
e
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the a ve-mntioned pr pert or inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitfee Ddle