HomeMy Public PortalAbout6139 AVON AVE_Electrical__ WORKERS'COMPENSATION cafe of
CE-06 19/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-606G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES —<111 AND SAFETY
or ya certifi copy thereof (Sec. 3800, Lab. C.) 7 -�
Poli No. 1 81Company a FOR APPLICANT TO FILL IN JOB s�
Certified copy is hereby furnished. New Residential Bldgs. & Pools
EACH NO. FEE ADDRESS 6Z3 !7 fJ E
S —
Certified copy is filed with the county building inspec- 1 & 2-Family, q• Ft. $ $ LOCALITY
Tion depa invent. (�/, Multi-family Sq. Ft. 'NEAREST
C29 �✓ L CROSS ST.Residential Swimming Pools OWNER OR eC
DateIL-3-Applicant FIRM NAME cv
CER IFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light Sw._ AIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Z CITY Tel. No.
the permit is for one hundred dollars($100)or less.) Additional
PLAN CHECK �
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation.Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Ak
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS tl �'
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY � /1-AJle Tel. No. —Foe
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other—
LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER 3-93/371
Class.��fi
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE ED BY
and Professions Code,and my license is in full force and effect. Power Apparatus & Large Appliances �✓ y
Size &Type HP KW KVA, or KVAR'
®.
License Number ��1 3 Lic. Class y. PUUpho 1 Incl. FINAL
10 - 2 Over 1 to 10 Incl DATE
�5— s- VALIDATION
Contractor ` Date Over 10 to 50 Incl. I-
FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY LM
Over 100
B.&P.C. for this reason
Services, Swbd., MCC & Panelboards
Date: 0 -200 Amp. Under 600 V ®�,�"
Signature 201 - 1000 Amp. Under 600 V c hffl 0 pUa pump sphka n subieCt
❑ � p�$ pts t
Exemption for Reg. Maint. Elect Over 1000 Amp. or Over 600 V 19L�
FO�r�E I« IP�St�Iff@1QQQn,
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit `
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code): c 0.015
0 0 q
❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors '
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , #'o o'o 0 0 2
7044, Business and Professions Code).
CONSTRUCTION.LENDING AGENCY
i 5, 2'5 .
1 hereby affirm that there is a construction lending agency for o 0 0 5,2 176
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). '
C� 22G -83
PLAN CHECKING FEE '
Lender's Name
PERMIT ISSUING FEE 0
Lender's Address (/
I certify that I have read this application and state that the TOTAL FEE 1v s Z}
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
7ve-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date