HomeMy Public PortalAbout9421 WOODRUFF AVE_Electrical__ y WORKERS'.COMPENSATION DECLARATION 76A663 10/81 1 o
., CE=806G • APPLICATION F®R ELECTRICAL PERMIT
•f=hereb firm that I have a certificate of consent to self insure, ,
ora cbrtitic4te of Workers' Compensation Insurance;or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
Copy there8f(Sec.3800,Lab.C.) i
Policy No. Company FOR APPLICANT TOTILL IN JOB �e G'e`
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS A
New Residential Bldgs.&'Pools $ _ $ LOCALITY � �L
.�erfified copy is filed with the county building inspection 1 &2-Family,Sq.Ft.
dep ent. A o Oy
�� .� R I Multi-fam..ily Sq.Ft. NEAREST
/ �� Residential Swimming Pools CROSS
Date Applicant OWNER// ur
FIRM NAME c j✓I,
CERTIFICATE OF EXEMPTION'FROM WORKERS' � MAIL
COMPENSATION INSURANCE• Outlets:Rec Light—Sw. ADDRESS
(This section need not.be completed if the work Involved by the 4 First 20 CITY Tel.No.
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of,the work for which this.permit PLAN CHECK
is issued, I shall not employ any person in arty manner so as to I', PPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 2.0 ADDRESS
Total No. Additional CITY Tel.Nm
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''12
provisions or this permit shall be.deemed revoked. Top — FAU gkf W.H. _ CITY Tel.No. j
LICENSED CONTRACTORS DECLARATION Hood —. Fan Other,_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR. ;O
Disp. Room Air Cond. REG.NUMBR C Class SIV'
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and.my license is in full force and effect: Power Apparatus&Large Appliances DISTRICT NO. PROCES D BY
1� Size&Type'HP,KW,KVA,orKVAR `5�} O.
&6Y.
License Nu.pmbe Lic.Class .. f _Up to 1 Inc[. tG (/f/ FINAL f
It 0 fr �-k+ Data —p Over 1 to 10 Inc[. DATE �� ALIDATION o
Contractor Over 10 to 50 Incl. FIN
❑ I am exempt under Sec. Over 50 to'100 Inc. BY tLl
B.&P.C.for this reason Over 100 �
Services,Swbd.,MCC'&Panelboards :.7 8 7.7 A Z
Date: ., 0-200 Amp..,Under 600 V
Signature 201 -;1000 Amp:Under, 600 V # 0 0 0 0 02
❑' Over 1000 Amp:or Over 800 V
Exemption for Reg.Maint.Elect. 0 0 5 1.7 5
+' SINGLE FAMILY' Temp,Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with-One Branch Circuit o 0 0 5 l,7 5'v
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions 0 9,'0 9—S 7
Code):
❑ 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
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(Sec.3097, PERMIT FEE (Sub-Total)
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 above TOTAL FEE hITT
information is corre .I agree to comply w'ifh all County,ord(nances
and State I s reatin Electrical wiring, and hereby-authorize
repro entat .iv of is . unty to enter Upon the above=ment1pned
p efor' ape o p rposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
Signaure,of,Per i ee' � , Date i