HomeMy Public PortalAbout6137 AVON AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 76A663 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm that I have a certificate of consent to self insure, _
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy No. - Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
Certified LOCALITY
❑ 1 &2-Family,Sq.Ft. $ — $ed copy is filed with the county building inspection NEAREST
department. r/ Multi-family Sq.Ft. CROSS S7.
Datepp ~► Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FlRM NAME
COMPENSATION INSURANCE S
(This section need not be completed if the work involved by the First 20 MAIL
permit is for one hundred dollars($700)or less.)
Total No. Additional ADDRESS
I certify that in the performance of the work for which this permit CITY' CI
Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECW
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date -- Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTI E TO APPLICANT: If, after making t is Certifica a of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH
PERMIT
APPLICANT 0 IN
provisions or this Dermit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH y_
LICENSED CONTRACTORS DECLARATION 15 OR 20A208V TO 277V LIGHTING EACH ADDRESS 0
I hereby affirm that I am licensed under provisions of Chapter 9 ,
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.5 7
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OA X
Power Apparatus&Large Appliances REG.NUMBER class. 0
License Number Lic.Class Size&Type HP,KW,KVA,Or KVAR DISTRICT NO. PROLE SED BY I°-•
_� U
Up to 3 Incl. �f W
Contract 0 �'� Date 7! Over 3 to 10 Incl. FINAL �
❑ Over 10 to 50 Incl. DATE /�
Z Z
I am exempt under Sec. y Over 50 to 100 Incl. Z`%FINAL Over 100 VALIDATION
B.&P.C.for this reason BY
Serrygi e S bd.,MCC�&iPanelboard
Date: WAC
Signature 201 -1000 Amp.Under 600 V
❑. Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect. s
SINGLE FAMILY Temp.Power Pole&Appurtenances '• T'
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits �-
Code): v
l :_I).Y
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors s} 7( 'r •.r P _f
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ' I_;'•,.� 99 '=
i -a-i'-=
CONSTRUCTION LENDING AGENCY Id �
',.;. Iti],.tu^
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.) =jam {;(iiy r;fjr;:•;
PLAN CHECKING FEE -•• -•
Lender's Name
PERMIT ISSUING FEE
Lender's Address I
I certify that I have read this application and state that the above TOTAL FEE ✓7G
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wirin !and hereby authorize
representatives of this County to enter pon the above-mentioned
operty for insp tion purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIMATURE OF APJI OR AGEN DATE
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