HomeMy Public PortalAbout5302 ZADELL AVE_Electrical_11/18/1986_ r WORKERS'COMPENSATION DECLARATION C6A � 10/e1 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I hava; a certificate of consent to self
insure, or a chrtificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified
.�copy thereof (Sec. 3800, Lob. C.) G-
P❑olicy No. Company 2M &6 FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH �0, FEE ADDRESS D I .
g g LOCALITY
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.tion department. Multi-family Sq. Ft. NEAREST
CROSS ST.
Date ApplicanOR
t
Residential Swimming Pools OWNER d 8 tan �y
FIRM NAME /�'.t V•A�e
CERTIFICATE OF EXEMPTION FROM ORKERS' Outlets: Rec�Light�Sw.� M' L
COMPENSATION INSURANCE ADDRESS
completed if the work involved b First 20
y Total Na.- Additional CITY Tel. No.
(This section need not be
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 manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures
� First 20 ADDR�SS
s
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 ® ' G 64*ax,
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood _ Fan _Other CITY �W"� Tel No. p:���Q
LICENSED CONTRACTORS DECLARATION LICENSE OR �+
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER YJMS Class. S
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PR ED BY per„'
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances 10— O ' O
_ Size&Type HP, KW, KVA, or KVAR r 00 0
License Number ® � Lic. Class 9 Up to 1 Incl. FINAL 0-'
Contractor. Date Ii Over 1 to 10 Incl. DATE _ VALIDATION
❑ Over 10 to 50 Incl. FINAL W
I am exemp nder Sec. Over 50 to 100 Inc. BY . N
B.BP.C. for this reason Over 100
Date: Services, Swbd., MCC&Panelboards n
0 -200 Amp. Under 600 V 1 n
Signature 201 - 1000 Amp. Under 600 V t/
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1
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): 1
❑ Misc. Conduits&Conductors
I, as owner of the property, will do the work and the \
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY ;-95967A
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) # 0 0 0 0 o 2
(Sec. 3097, Civ. C.). I - - 2600 0 2 6 O O
PLAN CHECKING FEE
Lender's Name 0 s
PERMIT ISSUING FEE o 00260025
Lender's Address
1 certify that I have read this application and state that the TOTAL FEE ( 1. 18"86
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
theabov enHan Zdrty for inspection purposes.
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
gna ure of Perm'to ri
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