HomeMy Public PortalAbout5329 ZADELL AVE_Electrical_9/11/1991_ WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87
I hereby affirmAPPLICATION FOR ELECTRICAL PERMIT Q
that I have a certificate of consent to self CE4306G
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 �+
Certified copy is hereby furnished. $ EACH $ LOCALITY '��NO. FEE ADDRESS AVS
New Residential Bldgs. &Pools _
Certified copy is filed with the county building inspec- 1 &2-Family,Sq. Ft. NEAREST
tion department. Multi-family Sq. Ft. CROSS ST. i
Date Applicant Residential Swimming Pools OWNEROR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' lght�Sw.� ` MAIL
Outlets: RecLi
COMPENSATION INSURANCE QADDRESS S A661
First 20
(This section need not be completed if the work involved by Total No.� Additional CITY Tel. No.
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 d ADDRESS
Additional
Date Applicant Total No. CITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION ®(V
VI
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. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
Disp. _ Room Air Cond. D LICENSE Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. ,RgPEESISEsD BY >_
and Professions Code,and my license is in full force and effect. a
�D (� L .�/' `�
Size&Type HP, KW, KVA, or KVAR O O
License Number Lic. Class ������������ ,.,U�P to 1 Incl. FINAL
U
itT. l1(i,�ver 1 to 10 Incl. DATE VALIDATION �O
Contractor Date hover 10 to 50 Incl. F-
❑ FINAL U
I.am exempt under Sec. Over 50 to 100 Inc. gY
Over 100 W
B.&P.C. for this reason / a
� Services, Swbd., MCC&Panelboards
Date' 0-200 Amp. Under 600 V Z
—
Signature 201 - 1000 Amp. Under 600 V
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit s
p Additional Si n Branch Circuits ` '3
Law for the following reason (Section 7031.5, Business and 9
Professions Code): w• (_,: i_, Iti
Misc. Conduits&Conductors
I, as owner of the property, will do the work and the
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ _
Business and Professions Code). ® =' H- 4Efi � I-.�(..e•
CONSTRUCTION LENDING AGENCY pjCj;; oi11�
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) 3a -;r.;�tt•jL F:1,;
(Sec. 3097, Civ. C.).
Lender's Name
PLAN CHECKING FEE
PERMIT ISSUING FEE l3Y
Lender's Address i ,_4 t`N
I certify that I have read this application and state that the TOTAL FEE _,45.
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
thea ve-mentioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signature of Permit ee Date ®°