HomeMy Public PortalAbout5329 ZADELL AVE_Electrical_10/16/1991_ „WORKERS'COMPENSATION DECLARATION 20.0010 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q
.I hereby affirm that I have a certificate of consent to self
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 r 2A
❑Certified copy is,hereby furnished. New Residential Bldgs. &Pools EACH NO., FEE ADDRESS
Certified'c.o is,filed with the count buildin inspec-, 1 &2-Famil .,S Ft. $ — $ LOCALITY
PY Y 9 P Y q•
tion department. Multi-family Sq. Ft. CROSS NEARES T.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec__LLight Sw._ MAIL
COMPENSATION INSURANCEt ADDRESS a
First 20
(This section need not be completed if the.work involved by- Total No. Additional a CITYI. No,
the permit is for one hundred:dollars($100)or'less.)
I.certify that in the performance of the work for which this I
'PLAN CHECK
permit is issued, I shall not employ any person.in any manner
so as to become subject to the Workers'Compensation Lawsi Lighting Fixtures First 20 ADDRESS
Additional
Date Applicant Total No. CITY - Tel.'No.
Fixed Appliances Not Over 1 HP,
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption, you should become subject to the 'Workers' Range— Heater—D.W. — APPLICATION
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—nd'.
LICENSE OR
Disp. _ Room Air'Conti. — REG.NUMBER Class.
' I hereby affirm that I am licensed under provisions of Chapter 9
(commenting with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P O SSED BY >•
and Professions Code,and my license is in full force.and effect: p d
Size&Type HP, KW, KVA, or KVAR C, O O,
License Number Lic. Class Up to 1 Incl. l• FINAL U
Coritractor Date Over 1 to 10 Incl. DATE f VALIDATION cc
:Over 1.0 to.50 Incl. r I—
FINAL
❑ U
I am exempt under Sec. Over 50.to 100 Inc. BY
B.&P.C. for this reason Over 100 Date: d
I Services, Swbd.., MCC&Panelboards r Z
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 I Temp. Power Pole&Appurtenances t,
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from'the Contractor's License Sign with One.Branch Circuit —
Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): �30I7 f f
❑ I, as owner of the property, will do the work and the Mist. Conduits&Conductors 17.6
7.
Other See Complete Fee Schedule Tr"'``
structure is not intended or offered for sale(Section 7044, ( P )— i .�I�?l�„
Business and Professions Code). + _ 1 , )1.1 TA.L '
CONSTRUCTION LENDING AGENCY I r m 63
1 hereby affirm that there is a construction lending agency for CHECK i7.63
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 3 CHANGE
.(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Addressl_ it��!
I certify that I have read this application and state that the TOTAL FEE 17. 101 95 16 y AM p,
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
` the above-mentioned property for inspgGtion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
®'
SigFirtLke of Permittee Date