HomeMy Public PortalAbout5930 AVON AVE_Electrical_3/30/1992_panelboard DECLARATI
WORKER'S COMPENSATION a certificate
of consent to s 20-OOt9DPW 9/89' �11�PIL�C6� 11 MN FOR ELECT ICAL PERMT
76A663 -
Ihereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(SeL,3800 Lab.C.) a
POIICy No.-------------,Company FOR APPLICANT TO FILL IN ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO: FEE — ?
LOCALITY
1&2-Family,Sq.Ft $
❑' _ — $ /-! �.4 (l. 1 E/ c �` 7 •�
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Residential Swimming Pools ASSESSOR
Date Applicant • ,- ;, MAP BOOK PAGE' ( PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR s7
Outlets:Rec._Light' SW. - .. FIRM NAME
.COMPENSATION INSURANCE —1-1-14
First 20 . MAIL`
(This section need.not be completed if the work involved by the Total No. Additional ADDRESS 59 30 Al Av,�;)/'
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit - CITY Tel.No.
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 ALPNIC NTK ".
Total No. Additional
ADDRESS
Date Applicant ' 15 OR-20A, BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making'this Certificate of CITY'. Tel.No.
Exemption,you should become subject to the-Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO'4,0 INCLUSIVE EACH PERMIT. -
APPLICANT
provisions or this permit shall be.deemed revoked.. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATIONADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
i (commencing with Section 7000) of,Divisi6n'3 of the Business and CITY - Tel.No. U
Professions Code,and my license is in full force_and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
Power Apparatus&Large Appliances REG..NUMBER class.
License Number Lia Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. P O SSED BY I"
p 0
Up'to3Incl. �d Gc¢� •� LU
Over 3 to 10 Incl. FINAL CL
Contractor. - Date •->- - - - - DATE -Over 10 to 50 Incl, I
❑ I am exempt under Sec. Over 50 to 100 Incl, tVz` VALIDATION
Over 100 - 'FINAL
B.&P.C.for this reason - BY "
Date:
Services,SWbd.,.MCC&Panelboards
�. Q
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. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit a +„
hereby affirm that I am exempt from the Contractor's,License Law
for the following reason (Section 7031.5,-Business and Professions Additional-Sign Branch Circuits .
`Code): -
I,as owner of the property,will do the work and the structure Misc,Conduits&•Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). -
::
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the _,,;;y;�€l•• ,, ,,.„
performance of the work for which this permit is issued (Sec. 3097, P-ERMIT.FEE (Sub-Total)
Civ.C.)'
PLAN CHECKING FEE
Lender's Name `
PERMIT ISSUING FEE
e Address
I certify
that I have read this application and state that the above TOTAL FEE
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
prop r ins p ction pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
3�3a
NA R OF APPLICANT ORA ENT DATE - - '