HomeMy Public PortalAbout9420-9422-9424 WOODRUFF AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION 'CE-806G (2-Bll) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY PF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'.Compensation Insurance,orC1 v��"
a certified copy thereof(Sec.3800,Lab.C.) T-W� a`7
.2 oZ
Policy No. Company FOR APPLICANT TO FILL IN SOB f
New Residential Bldgs.&.yPools p/ EACH NO. FEE —_ADDRESSQ
Certified copy is hereby,furnished. 1 &2-Family.Sq. Ft.�7�2 d L_ $ — $ LOCALITY72nr AA jot
❑ Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR ( (`
Date Applicant �ADDRESS
IRM NAME Ld
PP Outlets: Rec. Light Z Sw. 2v AIL
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional
COMPENSATION INSURANCE CITY Tel No.
PLAN CHECK a
(This section need not be completed if the work involved APPLICANT O0
Lighting Fixtur s First 20 io
by the permit is for one hundred dollars ($100) or less.) � ADDRESS
Total No. Z Additional cc
0
I certify that in the performance of the work for which this s Not Over 1 Hp CITY Tel No.
permit is issued, I shall not employ any person id any manner PERMIT Y V
so as to become subject to the Workers'Compensation Laws. Range_He ter D.W. Z APPLICANT (�v �/ W
CL
Oven � Dr er!W.M.-4 ADDRESS �-7 80` 1,�c X U)
Date//pp Top FA W.H. , ¢ Fq 7 c
l�pplicant. CITY Tel No. ( �
Hood � Fan �Other_
NOTICE TO APP.LICAIVT: If, after making this Certificate of Disp. 2 Roo .Air Cond. LICENSE OR U
Exemption, you should become subject to the Workers' REG.NUMBE 0C93q Class
Compensation provisions of the Labor Codd,you must forth- Power Apparatus Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP KW,KVA,or KVAR ry c���j—
U to 1 Incl. d
FINAL
"z O r 1 to 10 Incl. DATE �,7
LICENSED CONTRACTORS DECLARATION O r 10 to 50 Incl. VALIDATION
I hereby affirm that I am licensed under provisions of Chapter O r 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the Busi-' Ove 100 , BY i'�.•ol
ness and Professions.Code,and my license is in full force and ti
effect. Services
License Number�0;� Lic.Class
G f V 0-200 Amp.Under 600 V
.r o 201-1000 Amp.Under 600 V �y
Contractor.&/—lY%CL� Date S'•e02 Y �� Over 1000-Amp.or Over 600 V �G` _ �f y� j
Jq
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
I, as owner of the property;will do the work and the Other(See Complete Fee Schedule)— ;`= 1 2$3 A
structure is not intended or offered for sale (Section
7044, Business and Professions Code). #` o n 0 0 0 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE2 ° q-9 1.5 2
(Sub-Total)
issued(Sec.3097,Civ.C.). 0 0 0 9 1,05'2
Lenders Name PLAN CHECKING FEE (One-Fourth Permit Feel
22-81
Lender's Address !PERMIT ISSUING'FEE 09,
� ,
I certify that I have read this application and state that the TOTAL FEE / J
above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-m9ptioned yr9erty for inspection purposes. SEE'R'EVERSE.FOR EXPLANATORY LANGUAGE
Signatur of Permittee Date