HomeMy Public PortalAbout6268 RENO AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION 76A663 to/BI PAPPLICATION FOR ELECTRICAL PERMIT
_ I hereby aff4rm that I Piave a certificate of consent to self CE-806G
insure, or a ce.aificate•of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a fertified.copy thereof(Sec. 3800, Lab. C.)
Policy No. �' Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools
EACH NO. FEE ADDRESS O
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. NEARESTCROSS ST. D.f/
Date Applicant Residential Swimming Pools
FFIIRM NAME 4,1i
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Recto Light i3Sw. ' MAIL
COMPENSATION INSURANCE First 20 ADDRESS f?2-�O O
(This section need not be completed if the work Involved'by Total No. CITY Tel. No. zg.�
the permit is for one hundred dollars($100)or less.) Additional
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
,�+ � CITY Tel. No.
DateArY'17 pplicant4,. /Z SFixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If; after making is Certificate sof APPLICANT/ S < < C
Exemption, you should become subject to the Workers' Range— Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS 32� C101 40ep' A"
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan _Other— CITY Tel. IVo. 27V
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions-of Chapter 9 1 Disp. — Room Air Cond. REG. NUMBER , W r1 Class. G-/Ap
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESS BY
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances �/ IL
IL
Size&Type HP, KW, KVA, or KVAR' U[1Y
License Number d V Lie. Class Up to 1 Incl. FINAL U
Contractor Cele /01-1;" Over 1 to 10 Incl. DATE —1 _99 VALID TION 09
e'Date �� Over 10 to 50 Incl. V
❑ FINA
I am exempt under Sec. Over 50 to 100 Inc. BY au
BAP.C. for this reason Over 100
Service wbd., MCC&Ponelboards
Date: m Under 600 V
Signature 201 - 1000 Amp. Under 600 V .9_9 8 0 a 8 A
Exemption for Reg. Mainz. Elect. � Over 1000 Amp. or Over 600 V # 0 0 0 0 m.2
SINGLE FAMILY .� Temp. Power Pole&Appurtenances I o o39.75
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o 0 o39,755
Law for the following reason (Section 7031.5, Business and
Professions Code): I Q O$ 7
0 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
above information is correct. I•agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby a thorize representat es of this County to.enter upon
the ab a-ment' ned prop
y for inspe ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature o Permitt Date