HomeMy WebLinkAbout1001A (9)DEC
TION
76A
WORKERS' that
t I hove
a certificate
cafe of corse CE -803 10181 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE -806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified 'copy thereof (Sec. 3 Lab. C.) ,`.a
Polic No C m n � ` FOR APPLICANT TO FILL M !OB f!L
❑y o po y EACH NO. FEE ADDRESS a
Certified copy is hereby furnished. New Residential Bldgs. & Pools
Certified copy is filed with the county building inspec- I & 2 -Family, Sq. Ft. $ = S LCK'ALITY I �I
do de tmenI. '''(� thy, Multi -family Sq. FL. S(l NEAREST 1 U (D
( �Z �ApplicantLr Residential Swimming Pools OWNER OR J
Date 7 _
^^77�� FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Li9ht_ _.Sw.-5 MAIL
COMPENSATION INSURANCE+ / (J SV ADDR c.Z ( V,4
(This section need not be completed if the work Involved by ( First tCIN
the permit is for one hundred dollen (5100) or less.) Total No. Additional
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any mannerp
so as to become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 3 ADDRE
Additional
Total No. � CITY
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Healer—D.W. —
Compensation provisions of the Labor Code, you must forth- Oven —Dryer _ W.M. — ADDRESS „ f
with comply with such provisions or this permit shall be Top — FAU _ W.H- — CITY .0
deemed revoked. Hood _ Fon _ Other—
LICENSED CONTRACTORS DECLARATION LICENSE R
I hereby affirm that 1 am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO.
and Professions Code, and my license is in full force ongeffect: Power Apparatus 8 forge Appliances /
n � Size 8 Type HP, KW, KVA, or KVAR
License Nu } td� . Class -FINAL
/ Up to 1 Incl. DATE
-ha �4 Over 1 to 10 In
Contractor � are Over 10 to 50 Ind.
❑FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY
BAP.C. for this reason Over 100
Date: - -- Services, Swbd., MCC & Ponelboards ►
0 - 200 Amp. Under 600 V
Signature 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 1 am exempt from the Contractor's License Additional Sign Branch Circuits
Low for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits & Conductors
El
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm 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 Nome
PERMIT ISSUING FEE Q<7
Lender's Address
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
It by uthorize represent rives f this County to enter upon
e e Toned o rt inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Si o re of Permittee Date
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