HomeMy Public PortalAbout9064 RANCHO REAL RD_Electrical_1985-05-14 doll
._/WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I f�ereby affirm that I have a certificate of consent 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 FOR APPLICANT TO FILL IN JOB
ADDRESS Otal1
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE
❑ _
Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. $ $ LOCALITY
NEAREST
tion department. Multi-family Sq. Ft. — 1
CROSS ST. Lf {�AIJ
Date Applicant Residential Swimming Pools OWNER ORFIRM NAME G L'
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecZ Light Sw._ MAIL �`,(,`R
COMPENSATION INSURANCE First 20 2. v ADDRESS
(This section need not be completed If the work Involved by Total No. Additional CITY C t Tel. No.
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit 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 5IV—Pig'
Z/i rT/� Applicant llr �- L/�[7��°r Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
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. — CITY Tel. No.
LICENSED
revoked. Hood _ Fan _Other—
LICENSED CONTRACTORS DECLARATION LICENSE OR e& ljt
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG.NUMBER 702 Class. !!//
(commencing with Section 7000).of Division 3 of the Business DISTRICT NO. PROCES
ySjY
and Professions Code,and m license is in full force and effect. Power Apparatus&Large Appliances T-
`a C—
Size&Type HP, KW, KVA, or KVAR
r+
License Number d ' `— Lic. Class /� Up to 1 Incl. FINAL L)
ATE
i Over 1 to 10 incl. D / VALIDA N
or
Contractor6l �- &43ffk Date E`[y 6j❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY 9L
BAP.C. for this reason Over 100
Date: Services, Swbd., MCC&Ponelboards
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 s�2 2 4
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits a,0 0 0 0
Law for the following reason (Section 7031.5, Business and o 0
Professions Code): o - 270
❑ I, as owner of the property, will do the work and the 27.0
Misc. Conduits&Conductors 1 4 8�
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ , 0
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 �00
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
I
uthorize representatives of this County to enter upon
thea e-mentioned progRerty fop inspection purposes.
Sit'�y SEE REVERSE FOR EXPLANATORY LANGUAGE
atur 1tfee Date