HomeMy Public PortalAbout9735 WOODRUFF AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-
.: 8 6G (2.80) APPLICATION FOR ELECRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
"fl -
insure,or a certificate of Workers'Compensation Insurance,or / /
a certified copy thereof(Sec.3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
NO. FEE ADDRESS (�� (,j%-f ✓�
Policy No. Company
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ _ $ LOCALITY P4 a;-, Cj;y
Certified copy is filed with the county building inspection Multifamily Sq. miFt. CROSS ST �Q`y]E�tJ d✓l�.�]r'
department. Residential Swimming Pools OWNER OR
Date Applicant ' FIRM NAME QC:h 1+4 Z 'P6N/
Outlets: Rec.�Light �Fi s1t 20 • D � ADDRESS 3� 1Ut0 p aje Q FF /fVe
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY
COMPENSATION INSURANCE �jn JJ`� C/T Tel No. ,%F6 ST7�
PLAN CHECK a
(This section nedd not be completed if the work involved ell APPLICANT S`. F Lighting Fixtures First 20 U cc
the permit is for one hundred dollars ($100) or less.) Additional ADDRESS
Total No. o�.
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. O
permit is issued, I shall not employ any person in any manner PERMIT W
so as to become subject to the r Workers'Compensation Laws. Range_HeateD.W. _ APPLICANT a
r Oven _ Dryer_W.M._ ADDRESS co
Date - Y'A Applicant tiJ Top _ FAU _W.H.;_
Hood _ Fan _Other_ CITY el No.
NOTICE TO APPLICANT:Illif, after making this Certificate of Disp. _Room Air Cond ILICENSE OR
Exemption, you should become•subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESS
with comply with such provisions or this permit shall be ,
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl. Is r a
Over 1 to 10 Incl. FINAL
DATE
LICENSED,CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl. �
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY C11__1
- J--�
ness and Professions.Code, and my license-is in fulforce and U
l'
effect. Services
0-200 Amp.Under 600 V
License Number Lic.Class 201-1000 Amp.Under 600 V
Contractor Date Over 1000 AMP.or Over 600 V
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 Uw for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ;'-11 1 LI,5 A
ness and Professions Code): t- o o u o o f
Misc.Conduits&Conductors - -
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 1 0.00
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY 1 a,o n 1
0.U 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this ,permit is
PERMIT FEE (Sub-Total) � D d 091 11 -81
issued(Sec.3097,Civ.C.).,111_1
Lender's Name PLAN CHECKING FEE -(One-Fourth Permit Fee)
Lender's Address. PERMIT ISSUING FEE D
I certify that I have read this application and state that the TOTAL FEE od
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-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermittee Date ,