HomeMy Public PortalAbout5325 ZADELL AVE_Electrical_8/12/1991_ WORKERS'COMPENSATION DECLARATION 30.0019 DPW 3/67 '-APPLICATION FOR ELECTRICAL PERMIT O,
"by affirm'that I have a certificate of consent to self � 3
insure,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES } DEPT. OF PUBLIC WORKS
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �3 /��
❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS J / V
❑Certified-copyis filed with the count building $ = $ LOCALITY
y g inspec- 1 &2=Family, Sq. Ft.
tion department. ' Multi-family Sq.'Ft. NEAREST
i Residential Swimming Pools OW EN RST.
Date Applicant i FIRM NAME L
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ ANAIL
DDRESS
COMPENSATION INSURANCE First 20
(This section need not be completed If the work involved by , CITY Tel. No j a
the-permit is for one'hundred dollars($100)or less.) Total No. Additional C(.�
PLAN CHECK
I certify that in 4he'perforrriance-of the work for which thisAPPLICANT
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws. ; g g
1 �+ � Additional
Date Total Z– �(� aPx i91r r� Total No. CITY Tel. No.
Applicant
NOTICE TO APPLICANT: If, after makingthis Certificate of Fixed Appliances Not Over 1 HP PERMIT
PPLICATION
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 J
with co ply with such provisions or this permit shall be To —W:H. —
deemed mrp . — FAU evoked. Hood — Fan —Other— CITYTel. No. g/g
LICENSED CONTRACTORS DECLARATION ,. LICENSE OR "
Djsp. — Room Air Cond. — �t / Class.62a.cyt�
I hereby affirm that I am licensed under provisions of Chapter 9 ,I REG.NUMBER 3��i
(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.
Cl—Size&Type HP, KW, KVA, or KVAR � O
License Number YB 63 Lid. Class ems!Z1b4 Up to 1 Ind.. FINAL U
—� �_
4 I Over 1 to 10 Incl. DATE ?-2,7,VVALIDATION cr
Contractor.M :<.atI ICI Date ^ �7– �/ O
❑ Over 10 to 50 Incl. FINAL F-
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason 1 Over 100 d
7_Q Services,Swbd., MCC&Panelboards Z
Z
0-200 Amp. Under 600 V
Signature = ' 201 -1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances r'
'HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License ;;;�
Law for the following reason (Section 7031.'5, Business and Additional Sign Branch Circuits 1°v'
Professions Code): 33I7
property, I� Misc. Conduits&Conductors 4 y ;
EJ 1, will do the work and the
1, as owner of the. I
structure is not intended or offered for sale(Section 7044, + Other(See Complete Fee Schedule,)—
Business and Professions Code). ® i ;I AL ` 013
.�
CONSTRUCTION LENDING AGENCY I CHECK -20.l l;
I hereby affirm that there is a construction lending agency.for E_..
the performance of the work for which.this permit Is issued i PERMIT FEE (Sub-Total) °�l?
(Sec. 3097, Civ. C.),
PLAN CHECKING.FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address TOTAL FEE ONO 4'0 1 tlt�rc
'
I certify that I have read this application and state that the
iah l :�8°Jv
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby autho ize representatives of this County to enter upon
the above- ntione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nat Date ®'