HomeMy Public PortalAbout9522 WOODRUFF AVE_Electrical__ r WORKERS'COMPENSATION DECLARATION 20-0019 DPW.3/87 ' p� �+
I"hereby'dffirm that I have a certificate of consent to sel �E8006G appd �C�Q��®l�] FOR �d�C���B��� ��R11A11 O
insure, or a certificate of Workers'Compensation Insurance COUNTY OF LOS ANGELES ; DEPT. OF PUBLIC WORKS
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No895MZG802& 199 Calif Casual FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ; ADDRESS 9522 Woodruff
®Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date —Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTICA FROM WORKERS' Outlets: Rec Light Sw._ s MAIL
COMPENSATION INSURANCE First 20 I ADDRESS' 9522 Woodruff
(This section need not be completed if the work Involved by, Total No. Additional CITY Temple CityTel. No. _
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I'shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No.
Date Applicant j
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION Arc Mon Electric
Compensation provisions of the Labor Code, you must forth- Oven — Dryer W.M.— ADDRESS 124 W. Pomona
with comply with such provisions or this permit shall be Top — FAU `L W.H. —
deemed revoked. I Hood — Fan —other—
CITY Monrovia Tel. No.3589161.
LICENSED CONTRACTORS DECLARATION I LICENSE OR ' 503301 C-10
1 hereby affirm that I am licensed under provisions of Chapter 9 .l Disp. _ Room Air Cond. _ REG.NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances I DISTRICT NO. PROCESSED BY >_
and Professions Code,and my license is in full force and effect. y y� O
Size&Type HP, KW, KVA, or KVAR (/
License Number 5.03301 Lic. Class C—l0 1
Up to 1 Incl. 4 FINAL V
i
/! p —J Over 1 to 10 Incl. DATE .� ✓ Ix
Contracto/`u��C �•b% �t p Date �� v w o �I i � VALIDATION
1 Over 1.O,.to 50 Incl. �
FIN/{L❑ U I am exempt under Sec. Over 50 to 100 Inc.
LLI
B.&P.C. for this reason Over 100 a
pqt
I
ervices, Swbd., MCC&Panelboards co!
e'9,9 0-200 Amp. Under 600 V J Z
Cignature �— 201 - 1000 Amp. Under 600 V 1 si
❑ I Over 1000 Amp, or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION +
I hereby affirm that I am exempt from the Contractor's License j Sign with One Branch Circuit $�2,0 1 S2 A
Law for the following reason (Section 7031.5, Business and I Additional Sign Branch Circuits I ° ° 2 0 5
Professions Code):
0 0
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors ! o 0 o 2 a 5 0
structure is not intended or offered for sale(Section 7044, 1 Other(See Complete Fee Schedule)—
Business and Professions Code). ) D 0 73 3``8 8
CONSTRUCTION LENDING AGENCY
I i
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued I PERMIT FEE (Sub-Total) 25 51
(Sec. 3097, Civ. C.). I
PLAN CHECKING FEE
Lender's Name ,
PERMIT ISSUING FEE
Lender's Address � '
I certify that I have read this application and state that the I TOTAL FEE 25•. 5 C
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 a -mentioned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
L + I I ®s
Signature of Permittee Date l
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