HomeMy WebLinkAbout1727 SILVER RAIN DRWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C. )
Policy No. Compony
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec-
tion department.
Date Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the work Involved by
the permit Is for one hundred doliws ($100) or Iess.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Woor�k�rs'' Compensatiioor Laws.
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Date 4^L2e0 oppliconit
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License Number Lic. Class
Contractor Date
❑ I am exempt under Sec.
B.BP.C. for this reason
Date:
76A663 iD/B1
CE-806G APPLICATION FOR ELECTRICAL PERMIT
A06I(
OS OF, I(OS ANGELES BUILDING AND SAFETY /�
FOR APPDGANT TO FILL ADDRESS / / Z S%1 y /6/� /9' A1 /C
JOB
New Residential Bldgs. 8 Pools EACH NO. FEE
1 8 2-FamilY, Sq. Ft. $ — $ LOCALITY
Multi -family Sq. Ft. — NEAREST O JA
CRasssr. �/)
Residential 5 ming Pools OWNER OR
tp0. aO 150 FIRM NAME �dNa�R
Outlets: Rec_Lighl_5w._ MAIL
ADDRE L C7
First 20
Total No. Additional CITY � 1-,�Dg4.Vb je I. No.g4 74
Lighting Fixtures First 20
Total No. Additional
Fixed Appliances Not Over ) HP
Range_ Heater—D.W.
Oven _ Dryer — W.M. —
Top _ FAU — W.H. —
Hood _ Fan — Other—
Disp. Room Air Cond. —
Power Apparatus 8 Large Appliances
Size 8 Type HP, KW, KVA, or KVAR
Up to 1 Ind.
Over 1 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC 8 Ponelboords
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
❑Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole 8 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
J Prof scions Cade):
1, as owner of the property, will do the work and the Misc. Conduits 8 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
Lender's Address
I certif that I have read this application and state that the TOTAL FEE
y
above information is correct. I ee to amply with all County
ordina tes and State law egu r lectricol wng, and
here authorize represe otiv t ' County a er upon
t ove-mention er r pection urp es.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perminee Dote
APPLICANTyOW
ADDRESS
CITY
PERMIT
APPLICANT
ADDRESS
CITY
LICENSE OR
REG. NUMBER
DISTRICT NO.
FINAL
DATE
FINAL \ ee
BY � `
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Tel. No.
Tel. No.
Class.
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