HomeMy Public PortalAbout5930 AVON AVE_Electrical_3/8/1984_outlets WORKERS'COMPENSATION DECLARATION "76A663 10/81 APPUCQTION FOR ELECT TMICAL PERK T
I hereby affirm that I have a certificate of consent to self CE-606G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT.TO FILL IN' JOB ��
Certified copy is hereby furnished. New Residential Bldgs.,& O:Pools EACH NFEE ADDRESS/
❑ 1 8 2-Family, Ft. $ — $ LOCALITY
Certified copy is filed with the county building y� S9•
tion department. 'Multi-family Sq. Ft. — 'NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR
Ad-
Date Applicant FIRM NAME ~s %�C-41�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.� �- MAIL
COMPENSATION INSURANCE �t%fj 1 Z ADDRESS �►
This section need t be completed if the work involved r First 20
( eenop b Y Total No. Additional CITY Tel. No.
the permit is for one hundred dollars ($100)or less.)
PLAN CHECK
11 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 Wockets om ensotidn Laws. Lighting Fixtures First 20 ' ( ADDRESS
Total No. Additional
- Z CITY Tel. N .
• Da Applica`rf` � Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, aft making this Ce ificat f APPLICANT 4.
Exemption, you should become subject to the Workers' - Range_ Heater—D.W. u
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. LICENSE OR Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances _ o o
Size &Type HP, KW, KVA, or KVAR'
License Number Lic. Class Up.to 1 Incl. FINAL 63 <y
09
Contractor Date' Over 1 to 10 Incl. DATE �✓ VALIDATION 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 Over 100 N
D � .
Services, Swbd., MCC& Panelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
ElExemption
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
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and `9 5.23 A
Professions Code):
❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors # o 00 0 0 2
structure is not intended or offered for sale (Section Other (See Complete Fee.Schedule)_ 2'o!g 2 5 55 0
t
7044, Business and Professions Code). '
CONSTRUCTION LENDING AGENCY ..0 Po,'o 2 5,5.0 v
I hereby affirm that there is a construction lending agency for O.3 0 8'_8 4
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). -
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE ® �/
Lender's Address
I certify that I have read this application and state that.the TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby thorize representatives of this County to enter upon
the
,dbov me tin=popbrty for i pe ti purposes.
- SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permit Date