HomeMy Public PortalAbout9216 WEDGEWOOD ST_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81 AI PUC/TION FOR ELEdT®IC A L PERMIT
I hereby affirm ghat I have a certificate of donsent td self insure, CE-806G I 6�p EV 1'1 /� PERMIT
or a certificatg of Workers"Compensation Insurance, or a certified I COUNTY OF LOS ANGELES BUILDING AND SAFETY
�,po tthherep�f`(Sec.3800,Lab.C.) /
W II 'No. r / 7U Company 7 FOR APPLICANT TO FILL IN JOB
ADDRESS �j 47
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ;
_Dt_LJ 1 &2:.-Family, q•S Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection _
NEAREST
department. (� ,�J /J Multi-family Sq.Ft. CROSS ST
—/,41 Applicant �`�k /ILL Residential Swimming Pools OWNER OR
Date FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec —Light—Sw.— MAIL
COMPENSATION INSURANCE I I First 20 ADDRESS
(This section need not be completed if the work involved by the CITY �G l Tel.
permit is for one hundred dollars($100)or less.) Total No. Additional
1 certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not emjlloy any person in any manner so as to ! APPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel.No.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP 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. — CITYTel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan Other— U +A °v
LICENSE OR lr
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. U Cly /►
(commencing with Sectionr7000) of Division 3 of the Business and REG.NUMBER gC
Professions Code,and my license is in full force and effect. I DISTRICT NO. PRO SSED BY
Power Apparatus&Large Appliances
>--
020
0..,0 Size&Type HP,KW,KVA,or KVAR O
License Number/ d� Lic.Class `—l/ p to 1 Incl. FINAL (�
Contractor A ���� �'� Date —� y a ver 1 to 10 Incl. DATE I VALIDATION 0
Over 10 to 50 Incl. V
FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
Over, 100 IL
B.&P.C.for this reason i co
Services,Swbd.,MCC&Panelboards Z
Date: 0-200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit Fit((na
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits t
for the following reason(Section 7031.5,Business and Professions s33i7 a �)
Code):
Misc.Conduits&Conductors i T I EMS
❑ I,as owner of the property,will do the work and the structure Fee Schedule)
Complete is not intended or offered for sale (Section 7044, Business Other(, -, p ) — TOTAL I�� '�
and Professions Code). CHECK �1.00'�(�
. 00
CONSTRUCTION LENDING AGENCY I
1 hereby affirm that there is a construction lending agency for the111;)
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) (� '(
Civ.C.).
PLAN CHECKING FEE
Lender's Name IJOOO-13001 i1i 26i10i l
PERMIT ISSUING FEE 1P7 1 AM n n f
Lender Address C.l
s
1 certify that I have read this application and state that the above TOTAL FEE U
information is correct.I agree to comply with all County ordinances 1
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
propeqy-oJinspenjpwrposes.
// SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date I