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HomeMy Public PortalAbout6110 AVON AVE_Electrical_7/25/1991_service amp 4 y.th COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT ,7r:that I have a certificate of consent to self CE-806G O ,,..,�,, j. certificote of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ._; t,­j certified copy thereof (Sec. 3800, Lob. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE. ADDRESS4i:)110 ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST �n Residential Swimming Pools CROSS ST.OWNER OR Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Svv_ MAIL COMPENSATION INSURANCE First 20 ADDRESS i (This section need not be completed if the work involved by Total No. Additional CITY \ Tel. No. the permit is for one hundred dollars ($100)or less.) 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 manne so as to become subject to trkgrs'Comp sation La Lighting Fixtures First 20 ADDRESS Additional Date ppficani Total No. CITY Tel. No. F'xed Appliances Not Over 1 HP PERMIT NOTI E TO APPLIC NT: after m in is Certificate of APPLICATION Exemption, you should become subject to the Workers' Range-- Heater—D.W. x. Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS L with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY _ Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER ( Class. C (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY >_ and Professions Code,and my license is in full force and effect. �O r Size &Type HP, KW, KVA, or KVAR O License Nu er ` Lica Class " Up to 1 Incl. FINAL U o Over 1 to 10 Incl. DATE VALIDATION cr ontract-r ate 0 Over 10 to 50 Incl. FINAL IP I am exempt under Sec. Over 50 to 100 Inc. B < U Over 100 LLJ B.&P.C. for this reason t1 Z Date: Services, Swbd., MCC& Panelboards / Q Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit si^:t`tir Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): =--• -- ❑ Misc. Conduits&Conductors I, as owner of the property, will do the work and the - structure is not intended or offered for saleege ( t.Section 7044, Other (See Complete Fee Schedule)_ , t 41i`fi= o .Business and Professions Code).' " 135 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency forr''• HHS i-3E . the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) z„ (Sec. 3097, Civ. C.). PLAN CHECKING FEE - _ Lender's Name '=ii_°i PERMIT ISSUING FEE �3 ' Lender's Address -_ I certify that 1 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 r guI ting Electrical wiring, and ereby authorize represent ves of this County to enter upon t a e-menti d rop ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r nature o i t Datee ©s