HomeMy Public PortalAbout5537 PERSIMMON AVE_Electrical__ WORKERS'COMPENSATION DECLARATION -663 10/81
CE-9086 APPLICATION FOR ELECTRICAL PERMIT {�
i-hereby affirm that I have a certificate of consent to self insure, CLI
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy,thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN gDDRESS �;� % /L f'rfT°lJ
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
LOCALITY
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ _ $
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date -7Applicant e Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' � � � MAIL
COMPENSATION INSURANCE I Outlets:Rao Ight Sw. ADDRESS
This section need not be com leted if the work involved b the First 20
( p y Total No.� Additional CITY ��1� e", Tel.No. T-11 161
permit is for one hundred dollars($100)or less.)
PLAN
I certify that in the performance of the work for which this permit APPLICANT CHECK
is issued, I shall not employ any person in any manner so as to
become subject to the-Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HPPER
e /
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT �C�(/
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 6
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
CITY - - Tel.No.7L � /7
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSEMBBER ��(` Clas
REG.IS UMBER
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCE BY
Power Apparatus&Large Appliances a
Size&Type HP,KW,KVA,or KVAR UA U
License Number k)1 Lic.ClassUp to 1 Incl. FINAL
' ��'�-" Date �� V� Over 1 to 10 Incl. DATE V LIDATION Q
Contractor
E] Over 10 to 50 Incl. FINAL (~j
I am exempt under Sec. Over 50 to 100 Inc. BY 11,11
a
B.&P.C.for this reason Over 100 N
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V i&*'
Signature 201 - 1000 Amp.Under 600 V
El Exemption
1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. o!7 0 613 A
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # o o o 0 0 2
1 hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions 11 o o45.50
Code):
Misc.Conduits&Conductors ° ° ° 4 S 5 0 5
❑ I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
and Professions Code). 0 5 1 9d-87
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(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address -.
I certify that I have read this application and state that the above TOTAL FEE J t
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
property f in c ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature,fof Permittee Date