HomeMy Public PortalAbout5232 PAL MAL AVE_Electrical__ P. ;R ERS'COMPENSATION DECLARATION 76A663 10/8..1 gpp`aC.AT.IOIV FOR,ELE.CTRICAL PERMIT
:hrby1q��,,a��'ffirm that I have a certificate of consent to self CE-806G
�iiksur'e, 3T a•certific.te of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
�.,
Policy No. Company FOR APPLICANT TO FILL IN JOB /)
Certified cd is hereb furnished. Aa ADDRESS
PY Y New Residential Bldgs. &Prj �§ EACH NO. FEE �
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft:. i /t� $ — $ LOCA
1:1 �'J � \
NEAREST
tion department. Multi-family Sq. Ft. CROSS ST. 'L+�!
Date Applicant Residential SvWimming Pools OWNER OR
FIRM NAME i! /rJ
CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw._ v ADDRESS
his section need not be completed-if the work Involved by
First 20
R P Total No. ;Additional CITY G G , I. No.
the permit is for one hundred dollars.($100)or less.)
I certify. that in the performance of the work for which this PLAN CHECK Q
R APPLICANT i
permit is issued, I shall not employ any erson in any manner
so as to beco esu ct,to the Worke Compensation Laws. Lighting Fixtures First 20 ADDRES G�
/ Total No. 3 Additional CITY ,i Tel. N .�/
17
Datef Appiican - Fixed Appliances Not Over 1 HP PERM
NOTICE TO APPLICANT: If, .after making this e,tificate of ' APPLICANT �S
Exemption, you should become subject to the 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 Top — FAU —W.H. — /
deemed revoked. CITY �� 1 Tel. IVo 01 7
LICENSED CONTRACTORS DECLARATION Hood = Fin_ j—Other—
UCENS .OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. .. oom Air Cond: D REG.NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSE
and Professions Code,and my License is in full force and effect: 5c o
Size&Type HP., KW, KVA, or KVAR- O
License Number L.ic. ClassFINAL
„ Up.to 1 .Incl.
Over 1 to 10 Incl. DATE _ Z'. VALID N
Contractor Date Over 10 to 50 Incl. FIN
❑ I am exempt under Sec. Over 50 to 100 Inc. B
j In
B.&P.C. for this reason Over 100
Date:. Services, Swbd., MCC&Panelboar s 71�
0 -200 Amp. Under 600 V 5d' U
Signature 201 - 1000 Amp. Under 600 V 7(j Q 4.A
❑ Over 1000 Amp. or Over 600 V
Exemption for.Reg. Maint. Elect.
0 0 0 0 0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION I o o 4&2 5
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.7,031.5 E.
Professions Code):
I, as owner of the property, will do the work and the- Misc. Conduits&Conductors 8'7
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I 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)
(Sec. 3097, Civ. C,).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE V
Lender's Address
I certify that I have read this application and state that the TOTAL FEE I
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
�ereby authorize representatives of is County to enter upon
�ermittee
above-mentionedrty fo ' pection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
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