HomeMy Public PortalAbout6133 RENO AVE_Electrical__ • s•�„ WORKERS'COMPENSATION DECLARATION 76A663 10/81
• 9?eli�7''affirm that I have a certificate of. consent to self Insa CE-806G APPLICATION FOR ELECTRICAL PERMIT
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or a certificate of Workers' Compensation Insurance,or a certifi d COUNTY OF LOS ANGELES ,i BUILDING'AND SAFETY
copy thereof.(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
' I
Certified copy is hereby furnishedADDRESS. i New Residential Bldgs..&-Pools EACH NO. FEE )
❑
71
1 &2-Family,Sq.Ft.Certified copy is filed with the county building inspection
$ ' — $ ..I LOCALITY
department. I Multi-family Sq.Ft. — NEAREST
I CROS$ST.
Date Applicant Residential Swimming Pools ; OWNER.OR
1 1 FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets:Rec—Light_Sw.
.COMPENSATION INSURANCE � .ADDRESS
(This section'need not be completed if the work involved.by the First 20 '
permit is for one hundred dollars($100)or less:) Total No. Additional ! CITY Tel.No. d
ly. h certify that in the performance of the work for which this.per!it �. •PLAN CHECK
`1 is issued, I shall not employ any person in any manner'so as to t -APPLICANT
bece subject to the Workers'Compensation Laws. I Lighting Fixtures First 20 ADDRESS.
'oplI
/ ppTotal No. Additional CITY T
Date./� ��— G1_SApplicant l+x Fixed.A lienees Not Over 1 HP
NOTICE :TO APPLICANT: If, after making this Certificate lof pp PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer W:M._ ADDRESS
provisions or this permit shall be deemed revoked. Top _ FAU , W.H. _ CITY Tel.No.
LICENSED CONTRACTORS DECLARATION 1 Hood — Fan Other_
1'hereby affirm that I am licensed under provisions of Chapter,;9 Disp. Room Air Cond. (�J LICENSE OR Claw
(commencing with Section 7000)of Division 3 of the,Business andREG.NUMBER '
Professions Code,and my license is in full.force and effect: Power Apparatus&Large Appliances DISTRICT NO. /�/) PROCESSED BY
Size.&Type HP,KW,RVA,or KVAR
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License Number Lic.Class Up to 1 Incl. i ' FINAL
Contractor Date Over 1 to 10 Incl. DATE' /j( �, VALIDVON
Over 10 to 50.Incl. 1P FINAL`(f O
E] .1 am exempt under Sec. Over 50 to 100 Inc.
BY W
BAP.C.'for this reason Over 100
i • Services,Swbd.,.MCC&Panel.boards Z
Date: 0 200 Amp.Under 600 V
Signature ' 201 - 1000 Amp.Under 600 V J
Over 1000 Amp.or Over 600 V t
❑ Exemption,for Reg.Maint.Elect. i 9 11 A '
'SINGLE FAMILY I Temp.Power.Pole-&Appurtenances i
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0 0 2
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,.Business and Professions Additional.Sign Branch Circuits. I I o o.3600
Code): i
I,as owner of the property,will bo the work and the strAure
Misc.Conduits&Conductors
00036007:
is not intended.or•offered for sale (Section 7044, Business Other(See Complete.Fee Schedule) _ a 14-88
and Professions Code).
CONSTRUCTION LENDING AGENCY I
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.). I
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
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 for inspection purposes. ; SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date `