HomeMy Public PortalAbout9079 WOOLLEY ST_Electrical__ I
WORKERS'COMPENSATIONDECLARATION CE-886G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGE ES 271UILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or 10, "fl
a certified copy thereof(Sec.3800;Lab.C.)
Policy No. Corttpany FOR APPLICANT TO FILL IN j JOB 0 ���LLE
New Residential Bldgs.&Pools EACH NO. FEE ,
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ I LOCALITY
Multi-family Sq. Ft. — i NEAREST
El Certified copy is filed with the county building inspection CROSS ST .SU ^A 1J A 5
department. Residential Swimming Pools NE AME n P O�
q Pe r J
Date Applicant Outlets: Rec.--LightSw. MAI
First 20 ESS l 01 Woo -e
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY I C PL Ci U Tel No. SGNO
COMPENSATION INSURANCE I }
PLAN CHECK 0-
{ APPLICANT
(This section need not be completed if the work involved U
Lighting Fixtures First 20 -7 1
by the permit is for one hundred dollars ($100) or less..) Additional ADDRESS
Total No. Additional
I certify.that in the performance of the work for which thisF zed Appliances Not Over 1 HP CITY Tel No. , U
permit is issued, I shall not employ any person in any'manner PERMIT IL)
so as to become subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT a
• Oven _ Dryer._W.M._ � ADDRESS �
Date Applicant Top _ FAU _W.H.._
Hood — Fan _Other_ CITY Tel
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Condom LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code,you must foith- Power Apparatus&Large Appliances i DISTRICT NO. PROCE ED BY
with comply'with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR
deemed revoked. ' r
Up to 1 Incl.
FINAL
Over 1 to 10 Incl. DATE'
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. C5 `Ire) VALI DATI
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
IAL
BY
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100Cr
ness and Professions.Code,and my license is in full force and
effect. Services
0-200 Amp.Under 600 V l
License Number Lic.Class
• 201-1000 Amp.Under 600 V •
Contractor DateOver 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 Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 22 3 3 3.'1 A
structure is not intended or offered for sale (Section
7044,Business and Professions Code)'. # o 0 0 0 0 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency '2 o 0 1 9 5 0
for the performance of the work for which this permit is •�3
issued(Sec.3097,Civ.C.). PERMIT FEE (Sub-Total) p� o o'a 1 O .5 0 36'
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 4 208-80
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
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
theabove-mentioned prion purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ;
Signature of Permittee Da e