HomeMy Public PortalAbout6041 AVON AVE_Electrical_7/9/1982_services amp WORKERS COMPENSATION DECLARATION 63
CE806G (2 SO) APPLICATION FOR ELECTRICAL PERMIT
CE 8 i
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a,certified`copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL IN JOB `'
Policy No Companyl New Residential Bldgs &Pools EACH NO FEE ADDRESS 6 Dy N r /}VBO
Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY
❑ Multi family Sq Ft NEAREST
Certified copy is filed with the county building inspection CROSS ST ��`Ci j� (� CAIT
department Residential Swim in Pools OWNER OR �^psr-t k,1` FIRM NAME L�Y C sCd:S
Date Applicant Outlets Rec_Light Sw MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY �A#P_J&-L Tel No � >.COMPENSATION INSURANCE PLAN CHECKq y 7S- a
(This section need not be completed if the work involved APPLICANT /F / 0
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS U
Total No Additional CC
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0
permit is issued I shall not employ any person in any manner PERMITU
so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT Q LV,41J,0F W
�f pQ /� Oven _ Dryer_W M ADDRESS N
Date / O L'Applicant v Top FAU _W H z_
Hood Fan _Other_ CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond_ LICENSE OR
Exemption you should become subject to the Workers REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCE SED BY
with comply with such provisions or this permit shall be
deemed revoked _ Size&Type HP KW KVA or KVAR
Up to 1 Incl
FINAL sr
Over 1 to 10 Incl DATE
LICENSED CONTRACTORS DECLARATION
Over 10 to 50 Incl " $—ZZ VALIDATION
`
I hereby affirm that I am licensed under provisions of Chapter FINAL Over 50 to 100 Inc BY I^
9 (commencing with Section 7000) of Division 3 of the Busi Over 100
ness and Professions Code and my license is in full force and
effect Services
0 200 Amp Un r 600 V )
License Number Lie Class 201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION
Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits 4 8 7i2 A
ness and Professions Code)
Misc Conduits&Conductors # °'o o o o 2
I aowner of the property will do the work and the Other(See Complete Fee Schedule)—
structure
ture is not intended or offered for sale (Section
7044 Business and Professions Code) 210'-'5�5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ° ° o i5 3 5 0 5
for the performance of the work for which this permit is PERMIT FEE (Sub Total)
issued (Sec 3097 Civ C) a 0709-8,2
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender s Address PERMIT ISSUING FEE
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
hereby authorize representatives of this County to enter upon
theabb&e mentioned prop for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatuig of Permittee Date
1