HomeMy Public PortalAbout9932-9934 WOODRUFF AVE_Electrical__ WORKERS'COMPENSATION cafe of corse CE-&76A663 .10/81 APPLICATION FOR ELECTRICAL PtIMIT
I hereby affirm that I have a certificate of consent to self CE-8066
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.) I
Policy No. Company FOR APPLICANT TO FILL IN gDDRESS
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO.. FEE \
❑ Certified copy is filed with the county building inspec- y, q. LOCALITY L. Gf7
1 8 2-Family, S Ft. �� � $ —_ $ NEAREST
tion department. Multi-family Sq. Ft. CROSS ST. DWG
Date Applicant Residential Swimming Pools OWNER OR.
FIRM NAME U
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw._ LMDRES 4 �G
7Y lU�COMPENSATION INSURANCE
This section need not be completed if the work involved b First ti
( p y Total No. Additional CITY20
P2 C C Tel. No, �
the permit is for one hundred dollars(;100)or less.)
I certify that in the performance of-the work for which this APPLICANTK
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
Total No. Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven —Dryer. —W.M.— ADDRESS �/>�/�
with comply with such provisions or this permit shall be Top — FAU —W.H. — r
deemed revoked. CITY C ��� Tel.
Hood — Fan —OTher—
LICENSED CONTRACTORS DECLARATION LICENSE OR sz/!�'� �
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER oG l Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&targe Appliances DISTRICT NO. �-. PROCESSED BY =
and Professions Code,and my license is in full force and effect. ab
Size&Type HP, KW, KVA, or KVAR' a
License Number Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE W
6 �� VALIDATION O
Contractor Date Over 10 to 50 Incl. FINAL U
❑ I am under Sec.exempt Over 50 to 100 Inc. BY
LU
P Over 100
B.&P.C. for this reason
Date: Services,5wbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 -1000 Amp. Under 600 V
❑
Over 1000 Amp. or Over 600 V
Exemption for Reg. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code): 3 4.A
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 1` 0 0 0 0 0 2
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code). o o y g
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 PERMIT FEE (Sub-Total)
11.
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE 03-8c
Lender's Name
PERMIT ISSUING FEE •
Lender's Address
I certify that I have read this application and state that the TOTAL FEE o
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 abov hent' red proper, for inspection urposes.
SEE REVERSE FOR EXPLAPIATORY'LANIGUAGE
Signature ate