HomeMy Public PortalAbout9415 WOODRUFF AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-8 10/81
CE-80806G APPLICATION FOR ELECTRICAL PERMIT
r hereby affirm''that I have a certificate df consent to self insure, I
or a certificate-of-Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,1-ab.11)
Poll No it Company FOR APPLICANT TO FILL IN JOB
' –Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools `
y L1 Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ _ $ LOCALITY /3�
NEAREST
department. Multi-family Sq.Ft. CROSS ST. i
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME I� Al
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
Total NoCITY Tel.No.
permit Is for one hundred dollars($100)or less.) . Additional
PLAN CHECK
I certify that in the performance of the work for which this permit
APPLICANT
is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws. i Lighting Fixtures First 20 ADDRESS
O _/, Additional
_
C7�/d, I Total No. CITY Tel.No.
D Applicant_ /
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code,you must forthwith comply with such Oven ryerADDRE Al, � j/ ��A140provisions or this permit shall be deemed revoked. Top — H.
a/ Tel.N
LICENSED CONTRACTORS DECLARATION Hood — Fan Other— Cle
I hereby affirm that I am licensed under provisions of Chapter 9 isp. Room Air Cond. uCENSE OR
(commencing with Section 7000)of Division 3 of the Business and REG.NU 0 Class.
Professions Code,and .Po
m license is in full force and effect: I DISTRICT!)0 J PROC �,;EDBY
y wer Apparatus&Large Appliances �ltiJ �
� �� _ Size&Type HP,KW,KVA,or KVAR.
License Numb Lic.Class �' Up to 1 Incl. FINAL
� Over 1 to 10 Incl. DATE VALIDATION 0O
Contractor ?' I ate 9� Over 10 to 50 Incl. NAL ��..�.
❑ I am exempt unde ec Over 50 to 100 Inc. FINAL
W
B.&P.C.fo this reason Over 100
Da Services,Swbd.,MCC&Panelboards ® Z
t 0-200 Amp.Under 600 V ,
,S gnatu 201 - 1000 Amp.Under 600 V
E]/// Over 1000 Amp.or Over 600 V
( Exe F n for Reg.Maint.EI ct.
r`
SINGLE FAMILY Temp.Power Pole&Appurtenances _
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit A: T(fes nv
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 3307 46.0'-
Code);
6o[i-Code):
Misc.Conduits&Conductors I ITEMS
❑ I,as owner of the property,will do the work and the structure ) TOTAL Fee Schedulelets '(� 46 o��
is not intended or offered for sale (Section 7044,Business Other(See Complete — ®
and Professions Code).
46e00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CHANGE .0f.,
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total)
Civ.C.).
PLAN CHECKING FEE ` i?� �_I��� j f 13/99
Lender's Name
PERMIT ISSUING FEE 9487 1 AM 11 ii 11
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
a tate laws regu ting El Ing, and hereby authorize
pre nt s of thi o y rite upon the above-mentioned
f ection SEE REVERSE FOR EXP NATORY LANGUAGE ;
r
ignature of Permittee Date