HomeMy Public PortalAbout9227 WORKMAN AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION 76As83 .10/81 APPLICATION FOR ELECTRICAL PERMIT
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�' Sb� affirm that'I have a certificate of consent to self insure, CE-sosG
ortia'berhficate of Workers' Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. - Company FOR APPLICANT TO FILL IN JOB /'J
❑ Z�
Certified copy is hereby furnished. EACH NO. FE ADDRESS � (rQ/
New Residential Bldgs,&Pools $ _ $ LOCALITY
❑ Certified copy'is filed with the county building inspection 1 &2-Family,Sq.Ft
I NEAREST
department. Multi-family Sq.Ft.
Date Applicant ResidentiTug,
' mng Pools +`+ OWNER FIRM MOR
Al
CERTIFICATE OF EXEMPTION FROM WORKERS` Outlets:Rec ht Sw.[-v ��pp�� ^z
COMPENSATION INSURANCE First 20 20 DRESS , �• .W Jo 3
I (This section need not be completed if the work involved by the Total No. Additional
permit is for one hundred dollars($100)or less.) PCITY .e Tel.No. 1!,0/�
i LAN CHECK
I certify that in the performance of the work fog which this permit APPLICANT
I!
Is issued, I shall not employ an in arty manner as to
become subject to the Works ompe . tion Laws. Lighting Fixtures First 20 ADDRESS
4 Ze Total No. Additional CITY Tel.No.
Date Applicant Fixed Applia s Not Ove 1 HP ` PERMIT �
NOTICE TO APPLICANT: If, after making this Certificate of �° APPLICANT v� 6.lrQi
I, Exemption,you should become subject to•the Workers'Compensation Range_ Heater D.W.
I; 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.
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_ CITY 'S TeI..No:
I I hereby affirm that I am. licensed under rovisions of Chapter 9 LICENSE OR
�i y p Disp. Room Air Cond. _
(cbmmencing with.Section 7000)of Division 3 of the Business and REG.NUMBER Class.
Professions Code,and my license.is in,full force and effect. power Apparatus&Large Appliances•': DISTRIC-NO. PROCESS ,BY
- Size&Type HP,KW,,KVA,or KVAR �
License Number Lic.Class Up to.1'Incl. FINAL (�
DATE
4 Over 1 to.10 ipcl. VALIDATION O
I, Contractor Date Over 10 to 50 Incl.:
FINAL
li ElI am exempt under Sec. Over 50 to 100 Inc. BY
f pW, `
B.&P.C.for this reason Oyer 100
Services,Swbd.,MCC&Panelboards N
I; Date: 0-200 Amp.Under 600 v 8 5 5 7 A LER
Signature 201 - 1000 Amp.Under 600 V'
j 0 -0 0 0 0 2
Over 1000 Amp.or Over 600 V
I' ❑ Exemption for Reg:Maint.Elect. I
•o o 65.10
I'
I' SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit a o o 6 V 0
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 12 o9�8 7
Code): '
Misc:Conduits&Conductors
+
I,as owner of the property,will dot`e work and the structure Other(See Complete Fee Schedule) _
is not intended or offered for sale Section 7044., Business pop. ,
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm,that there is a construction lending agency for the
performance off 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 V
Lender's.Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct.I agree to comply with all County ordinances
and .State laws. regulating Electrical wiring, and hereby authorize
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tatives of this County to enter upon the above-mentionedforinspecfi0rses. SEE.REVERSE FOR EXPLANATORY LANGUAGE of Permit ee Date