HomeMy Public PortalAbout9161 WOOLLEY ST_Electrical__ WORKERS'COMPENSATION DECLARATION ICE-806 10/81 �PPLICATI N FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self i
CE-BO6Ginsure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs. &Pools
❑ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ _1$_—LOCALITY
tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR. �
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets: Rec Light Sw._
COMPENSATION INSURANCE ADDRESS
First
This section need not be com lotod If the work involvad b ti �j�
( p Y Total No. Additional CITY Tel. No.2�V! 3
tho permit is for one hundred dollars($1100)or less.)
I certify that in the performance of the work for which this PLAN C
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
_3 1/ � Total No. Additional
3 6d'�p CITY Tel. No.
Date pplicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE D16APPLICANT: 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. —
deemed revoked. CITY Tel. IVo.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other ' .� 49 icc
Disp. _ Room Air Cond. �j LICENSE O ? class.�,a/�
I hereby affirm that I am licensed under provisions of Chapter 9 , REG. NUMBER .!
(commencing with Section 7000)of Division 3 of the Business power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR ?
License Number !�� 1/3 Lir. Class C� e� Up to 1 Incl. FINAL 0
cc
23 Over 1 to 10 Incl. DATE -�3 VALIDATION 0
Contractor a Over 10 to 50 Incl.
FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY ��. �...� 2
BAP.C. for this reason Over 100 L H
Services, Swbd., MCC&Panelboards �j
D e: 0 -200 Amp. Under 600 V 6 l`
Signature 02 ,f 201 - 1000 Amp. Under 600 V
❑
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
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):
❑ I, as owner of the property, will do the work and the M,sc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)-
7044, Business 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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE -
Lender's Name
PERMIT ISSUING FEE O
Lender's Address G.p
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
the above-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a3 3
Sign ture o Permittee Date
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