HomeMy WebLinkAbout1651AWORKERS' COMPENSATION DECLARATION 76-663 10/87 APPLICATION FOR ELECTRICAL PERMITIherebyaffirmthatIhaveocertificateofconsenttoselfCE -806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETYoracertifiedcopythereof (Sec. 3800, Lab. C.)
Policy 102,277AID—SO_Compony INA
i Certified copy is hereby furnished. -
Certified copyls filed with the county building inspec-
tion department -
Date 7. 22-25 Applicont _ u 11ELECTRICJa
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
This section need not be completed N the work imrohred by
the permit is for one hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this
permit is issued, t shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Dote-- - Applicant -
NOTICE TO APPLICANT- If, after making thisCertificateof
Exemption, you should become- subject to the Workers'
Compensation provisions of the tobw Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked. -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I 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 47Q748 tic. ClassRr—1
Contractor RIaCf riCaT Date 7-22-21;
I am exempt under Sec.
B.&P.C. for this reason
DExemption for Reg. Moint. 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):
1, as owner of the property, will do the work and the
structure is not intended or offered for safe (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 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 Name
Lender's Address
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-mentioned property for inspection purposes.
Signature of Permittee — Date
FOR APPLICANT TO FILL
New Residential Bldgs. et
18 2 -Family, Sq. S
Multi -family Sq. Ft.
Residential Swimming Pools
Outlets: Rec_Light_Sw._
First 20
Total No. Additional
Lighting Fixtures First 20
Total No.
Additional
Fixed Appliances Not Over I 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 I Incl.
Over i to 10 incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC 8 Panelboards
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over Wo V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign &onch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)_
PERMIT FEE (Sub-Toto7)
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
0
CITY
ADDRESS
CITY Tel. No.
PERMITAPP"NT am"
ADDRESS
CITY chino Tei. No. _ 6461
UCPNSE OR
REG. NUMBER-A71717AA- Class _
DISTRICT NO. - PROCESSED BY
16
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