HomeMy Public PortalAbout6222 RENO AVE_Electrical__ F11 WORKERS'COMPENSATION DECLARATION 76A669 10/81 APPLICATION FOR ELECTRICAL- PERMIT
,. ' \:1`herel�y affirm that'I have a c6rtificate of consent to self CE-806G mil Ile
#,insure, of a certificate o#,Workers"Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
'
,or a,certified copy thereof(See. 3800, Lab. C,)
.s�,p,�e
Policy No. id Company i �yoiy G p� FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools
rEACH NO. FEE ADDRESS
1 &2-Famil S Ft. — $ LOCALITY a
Certified copy is filed with 4NF
unty building in pec- y' q' NEAREST
tion department. Multi-family Sq. Ft. —
Residential Swimming Pools CROSS ST. �� q
Date Applicant OWNER OR 'r
FIRM NAME � Z��/ TTT/
CERTIFICATE OF EXEMPTIOM WO RS' Outlets: Rec Lighl Sw. MAIL'
COMPENSATION INSURANCE S oFirst 20 40 ADDRESS $'20
(This section need not be completed if the work involved by Total No. Additional T1
CITY W L f Tel. No
the permit is for one hundred dollars($100)or less.). PIAN 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 7 First 20 PU ADDRESS
Total No. Additional CITY Tel. No.
Date Applicant 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. —
deemed revoked. Hood _ Fan _Other_» CITY Tel. No.
LICENSED CONTRACTORS DECLARATION r ® LICENSE.OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Gond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO, PRO E ED BY
and Professions Code,and my license is in full force-and effect. Power Apparatus&Large Appliances
Size&Type HP, KW, KVA, or KVAR'
License Nuer Al. Lic. Class Up to 1 Incl. FINAL Iffi
Over 1 to 10 Incl. DATEq__, L VALIDATION 0.
ContractorA ate Over 10 to 50 Incl.
FINAL
❑ I am If un Sec. Over 50 to 100 Inc. I BY 911611
Over 100
B.&P.C. for this reason `V)
Date:
Sere' " MCC&Panelboards e J•I 6
0 -200 Amyl Under 600 V �`' I o� 01 1 &2A
5ignafure 20 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect, Over 1000 Amp. or Over 600 V # 0 0 0 0 0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances I o o 5 4,2 5
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 0 0 0 5 Ll,2 5 FJ
Law for the following reason (Section 7031.5, Business and I2-06-84
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).
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
Lender's Address
I certify that I have read this application and state that the TOTAL FEE "r
above information is correct. I agree to comply with all County
ordinances and State laws re ulating Electrical wiring, and
hereby authorize representati s of this County to enter upon
the above-mentioned prop e y for inspection urposes.
ffwv SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitte Date '
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