HomeMy Public PortalAbout9627 WOODRUFF AVE_Electrical__ WORKERS'COMPENSATION DECLARATION , CEA806 to/ei A®i�1��'CATION FOR ELECTRICAL PERMIT {�
I•hereby affirm that I have a certificate of consent to self insure, CE,BoaG A P IJ
or a certificate of Workers' Compensation Insurance, or a certified ,, COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thareof-(Sec.3800,Lab.C.) ,
FOR APPLICANT TO FILL IN .JOB
Policy No. Company ADDRESS
❑
Certified copy is hereby furnished. New Residential Bldgs.&Pools . EACH NO. FEE
❑ AQ — d p
Certified copy is filed-with the county building inspection 1 &2-Family,Sq.Ft. $,71 LOCALITY
department. Multi-family Sq.Ft. — NEAREST
CROSS ST
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE.OF EXEMPTION FROM WORKERS" Outlets:Rec—Light —Sw.= ` MAIL
COMPENSATION INSURANCE First 20 ADDRESS ,
(This section need not be completed if the work involved by the CITY Tel.No. � y
perriiit•is•for one hundred dollars($100)or less.) Total No. 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. Lighting Fixtures First 20 ADDRESS
Additional
' Total No. CITY Tel.No.
Date Applicant A Fixed Appliances Not Over 1 HP PERMrr
NOTICE TO APPLICANT: If, after making this Certificate ofAPPLICANT !
Exemption,you should become subject to the WorkersCompensation Range_ Heater D.W.
provisions of the Labor Code,you must forthwith.comply,with such Oven — Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top _ FAU -_ W.H.
CITY L �f7 Tel.No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other._
I hereby affirm that I am licensed under provisions of Chapter 9
LICENSE OR
(commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.C.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO.. BY
�r�� Size&Type HP,KW,KVA,or KVAR
License Number Lic.Class Up to 1 Incl. FINAL
'Over 1 to 10 Incl. DATE ) VA_LIDATION O
Contractor L tate 40 Over 10 to 50 Incl. L 11--
FINAL
V
❑ , I am exempt under Sec. Over 50 to 100 Inc. BY, a
B.&P.C..for this reason Over 100 N
Services,Swbd.,MCC&Panelboards
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. �''-'�^''"^''-'���T�T�-
SINGLE FAMILY I Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION ' Sign with One Branch'Circult ��14L1
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
Code): { �L
Misc.Conduits&Conductors , 31 1i�o�79
❑ I,as owner of the property,,will do the work and the structure
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 5-0
Lender's Address TOTAL FEE
I certify that I have read this application and state that the above •
Information is correct.I agree to comply with all County ordinance.§
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
prop
9rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ZZ
Sqbaetffre of r itte Date