HomeMy Public PortalAbout9506 WEDGEWOOD ST_Electrical__ WORKERS'COMPENSATION DECLARATION 78-8 10/81
CE-80BG APPLICATION FOR ELECTRICAL PER
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.,-Lq hdreby affirm that I have a certificate of consent to self insure, Io8
or-a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy4hereof(Sec.3800,La C.) �) f� l
Poli No.. UUL �vCOmpany AW f `v( FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. I EACH NO. FEE -DDRESs W�9(� Wt;60 �tt,,
l� New Residential Bldgs.&Pools
❑ Certified co Is filed with the co1 &2-Family,Sq.Ft. $ — $ LOCALITY
copy ynty building�- pection —
(.1147
department. .a/ Multi-family Sq.Ft. NEAREST
CROSS ST.
DateApplicant Residential Swimming Pools OWNER OR n
FlRMNAME ILQpltif^ C}B�
CERTIFICATE OF EXEMPTION FROM, KERS' ,r MAIL
COMPENSATION INSURANCE Outlets:Rec Light— — [r ADDRESS
(This section need not be completed If the work involved by the Firstt 2 20
permit Is for one hundred dollars($100)or less.) Total No. Additional CITY ��� C/TY Tel.
I certify that in.the performance of the work for which this permit APPLICANT CHECK
is issued, I-shall not employ any person in any manner so as to
become subject to the Workers'Compen ation Laws Lighting Fixtures First 20 ADDRESS
Total No.0–I& Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after m this Certificate of APPLICANT
Exemption,you should become subject a Workers'Compensation Range_ Heater D.W. /�
provisions of the Labor Code,,yoLI'must.forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS �1W�
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _
CITYt CO!/�/!�%�, Tel.No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 I LICENSE B
Disp. — Room Air Cond.. REG.NUMBER 7 0�/t Class,
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect. i Power Apparatus&Large Appliances DISTRICT NO. PROCESSE�Y
Size&Type HP,KW,KVA;or KVAR
� y s
Icense Number . 1AAW LinClass Up to 1 Incl. FINAL �7
Over 1 to 10 Incl. DATE / 1 Z C VALID ION O
Contractor a Over 10 to 50 Incl. FINAL'!/ C/
❑ I am exempt der Sec. Over 50 to 100 Inc. a
BAP.C.for this reason Over 100 N
Services,Swbd.,MCC&.PanelboardsZ
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
I hereby affirm that I am exempt front the Contractor's License Law Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business anti Professions '}
Code):
' i)t_ t =
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors a t
is not intended or offered for sale (Sect)on 7044, Business Other(See Complete Fee.Schedule) _ Poo. ' L 17 w;I.l.O 13
and Professions Code).
I NEMS
CONSTRUCTION LENDING AGENCY 30�r-
0
I hereby affirm that there is a construction lending agency for the !IT AL ..:
Performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHECK 7-21.05
PLAN CHECKING FEE CHANE`
Lender's Name ,J
PERMIT ISSUING FEE (J
�l
Lender's Address TOTAL FEE O 0 n i l 1'' '7`
I certify that I have read this'application and state that the above• (/ a I
information is correct:I.agree to comply with all County ordinances I�C}Q } Z+ �i'�= t.
and State laws regulating Electrical wiring, and hereby,authorize I. 48
representatives of this County.to�enter
�'upon the above-mentioned
property fo inspection rpo eL.G SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature mittee Date