HomeMy Public PortalAbout5325 ZADELL AVE_Electrical_6/21/1991_ .W RKERS'COMPENSATION DECLARATION zaooiv oPw VV
R 'I hereby-affirm ;that :I •have a certificate of consent to,self APPLICATION FOR -ELECTRICAL PERMIT
CE-80613
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof(Sec. 38.00, Lab.C.)
Po i y No. orripany :_ FOR APPLICANT TO FILL-IN JOB �L
Certified copy is hereby furnished. New'Residential'Bldgs. &Pools EACHZZ ZAZ
NO. FEE
ertified copy is.filed with the ca,unty b' 'Iding inspec= `.1'&2-Family,;Sq..Ft. - - $ -
ADDRESS �`
LOCALITY
tion department. Multi-famil S Ft. NEAREST -
Y q•
Date "� Applicant-0SURANCF0
T.
Residential Swimming PoolsOW.N RSOR
FIRM NAME _LLCERTIFICATE OF EXEMPTIOORKERS' /Q MAILOutlets:.Rec�Light Sw._ ADDRESSCOMPENSATION l k
First 20 �.
(This section need not be completed if the-work involved by CITY' Tel. No.
the permit'is for one hundred dollars($100):or less.) Total No.= Additional ; / D .Cc .
PLAN CHECK
I certify that in the performance of the work for which.this APPLICANT. I.,e-,
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 i �• ADDRESS 1
Total No. Additional
CITY Tel, No:
Date Applicant
'
Fixed Appliances Not Over 1 HP PERMIT.
NOTICE. TO APPLICANT: If, after making'this-Certificate of APPGICAT,ION r
Exemption, you should become subject to.the•Workers' Rarige— Heater—DLW. —
Compensation provisions of the Labor Code, you must forth.,. Oven — Dryer L.W.M.— ADDRESS t ,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 n LICENSE OR
Disp. — Room Air Cond. Class..
I-hereby affirm•that:l am licensed'under•provisions of Chapter 9 R .NUMBER
(commencing with Section 7000)of D.ivision'3 of the Business. Power Apparatus&Large Appliances DISTRICT NO. PROED BY
and Professions Code,and my license is in full force and effect. a
Mae&Type HP, KW,.KVA;or KVAR �o G« - O
License Number ® Lic. Class Up to 1 Incl. FINAL U
�7•�_�/ : �,. ,;� s-f Over l to'l0lncl. -=Z' . cc
��"�� DATE VALIDATION
cc
Contractor Over 10 to 50 Incl. L Ir-
.1❑ am exempt under Sec. Over 50 to 100 Inc. gy A
W
BAP.C. for this reason Over 100 d
z
Services, Swbd.., MCC&Pahelboards Z
•Date: 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
Temp. Pole.&Appurtenances f
-.
HOME OWNER-BUILDER DECLARATION i
I hereby affirm that I am exempt fromSign.with One Branch Circuit
'the Contractor's License
Law for the following reason (Section.7031.5, Business and Additional'Sign Branch Circuits
Professions Code): 11
❑ :I, as owner of Misc. . Conduits&the property, will do.the work and the. Conductors I ITEM'S
structure is not intended br offered.for sale(Section 7044,, Other(See Complete Fee Schedule)_ '.
Business and-Professions Code): W. TOTAL 63- 10
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is-a construction lending agency forO�t fi'''r`fit
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total.) ( ,0 CHANGE
(Sec. 3097, Civ.. C.').
PLAN CHECKING FEE
Lender's,Name ' t �F�
PERMIT ISSUING FEE T [(000-011101 ti/sV71 1.
Lender's Address TOTAL FEE / 7625 1 AM �n.32
.I certify that I have read this application and state that-the +y'�✓C)
above information is correct.'I agree to comply with all County
ordinances and.State ,laws regulating Electrical wiring, and
hereby authorize reApresent fives of thikCounty to enter upon
the above-menti pr erty for inspection purposes. SEE REVERSEFOR EXPLANATORY LANGUAGE
Signature or Date ®`
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