HomeMy Public PortalAbout5720 OAK AVE_Electrical_12/8/1982_WORKERS' COMPENSATION DECLARATION CE 863 ID,BI APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE806G
insure, 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. Compam� _
FOR APPLICANT TO FILL IN
❑ Certified copy is hereby furnished.
New Residential Bldgs. & Pools I EACH NO.
❑ Certified copy is filed with the county building inspec-
1 & 2 -Family, Sq. Ft
$ _ $
tion department.
Multi -family Sq. Ft.
Over 100
Residential Swimming Pools
Services, Swbd., MCC & Ponelboards
Date Applicant
0 - 200 Amp. Under 600 V
CERTIFICATE OF EXEMPTION FROM WORKERS'
Outlets: Rec_Light_Sw
Over 1000 Amp. or Over 600 V
COMPENSATION INSURANCE
First 2._
0
(This section need not be completed if the work Involved by
Total No. Additional
the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in anymanner
so as to be ome subject to the Workers' Com pen f a Laws.
Ughting Fixtures First 20
t
Total No. Additional
�/I/
\Date f Y Applicant �~
Fixed Appliances Not Over 1 HP
NOTICE TO PPLICANT: If, aft r making Ihis Ce tificate of
Exemption, you should beco subject to the Workers'
Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth-
Oven —Dryer — W.M. —
with comply with such provisions or this permit shall be
Top FAU — W.H. —
deemed revoked.
Hood _ Fan _ Other_
LICENSED CONTRACTORS DECLARATION
Disp. Room Air Cond.
_—
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
Power Apparatus & Large Appliances
and Professions Code, and my license is in full force and effect.
License Number I ic. Class
Contractor Date
❑ I am exempt under Sec
B.&P.C. for this reason
Date:
Signatur=
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
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
(Sec. 3097, Civ. C.),
Lender's Nam=
Lender's Addre—
I certify that I have read this application and state that the
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
th above-mentione r erty for inspection purposes.
�( �P.,, Iv/ik
nature of Perm itte d 1 Date
Size & Type HP, KW, KVA, or KVAR
81601+
Up to 1 Incl.
is ..7
Over 1 to 10 Incl.
" •GC,� _
Over 10 to 50 Incl.
n'a -2350 _
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Ponelboards
I `
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
I
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)_
I
PERMIT FEE
PLAN CHECKING FEE
(Sub -Total)
JOB-7�/ ,/°�
FEE I ADDRESS S /c SID . U!orl
LOCALITY
NEAREST
ST.
OW ER OR I,
FIRM NAME JO pt/4
MAIL LL
ADDRESS J��lJ A)O.
CITYV AW,,. CJ 1T4 Tel. No. `'S gao9
PLAN NECK r
APPLICANT
ADDRESS
CITY Tel. N/
PERMIT /
APPLICANT
ADDRESS
CITY Tel. No.
LICENSE OR Class.
REG. NUMBER
DISTRICT NO. PROCES D BY1,
O J
FINAL
DATE
VALIDATION
FINAL
BY
/1- ►
PERMIT ISSUING FEE 0 �6
TOTAL FEE
o—
SEE REVERSE FOR EXPLANATORY LANGUAGE
81601+
is ..7
" •GC,� _
n'a -2350 _
PERMIT ISSUING FEE 0 �6
TOTAL FEE
o—
SEE REVERSE FOR EXPLANATORY LANGUAGE
APPROVALS DATE INSPECTOR'S
SIGNATURE
TEMP. POWER POLE
UNDERSLAB WORK
i ROUGH CONDUIT
WIRING
FIXTURES
POWER AUTHORIZED
UTILITY CO. NOTIFIED
FINAL Enter on 5ronf
NOTES .
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5,
Business and Professions Code): Any city or county which
requires a permit to construct, alter, improve, demolish,
or. repair any structure, prior to Its Issuance, also re-
quires the applicant for such permit to file a signed state-
ment that he is licensed pursuant to the provisions of the
Contractor's ,License Law_ (Chapter 9 (commencing with
Section 7000) *of Division 3. of the Business and Profes-
sions Code) or that he is exempt therefrom and the basis
for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the appli-
cant to a civil penalty of not more than five hundred
dollars ($500)..
❑ I, as owner of the property will do the work, and
the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contrac-
tor's License Law does not apply to an owner of property
who builds or Improves thereon, and who does such
work himself provided that such Improvements are not
intended or offered for sale. If, however, the building or
Improvement Is sold within one year of completion, the
owner -builder will have the burden of proving that he did
not build or improve for the purpose of sale.)
I am exempt under Sec.
B & P.C. for this reason
Date
Owner