HomeMy Public PortalAbout6145 AVON AVE_Electrical__ (3) �.VYORKERS COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
��herRb,Y;J affirm that I have a certificate of consent to self CE 806G
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 DDRESS / Q/V •
PolC:-
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
m L
Certified copy is filed with the county building m1 & 2 Family y S q Ft $ — $ LOCALITYNEAREST ^
do dep tment Multi family Sq Ft
Residential Swimming Pools CROSS ST L
1Date Applica s OWNER OR
j FIRM NAME
CERTI ICATE OF EXEMPTION FROM WORKERS Outlets Rec-2s.—L ght . Sw ( MAIL
First 20
COMPENSATION INSURANCE ADDRESS P(7 13N.
(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
1 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 ecome sublect to the Wo r Compens to aws Lighting Fixtures First 20 ADDRESS
Total No Additional
CITY Tel No
Date ApplicanT Fixed Appliances Not Over 1 HP PERMIT
NOTI TO APPLICANT If after making this Certificate of �/ APPLICANT
Exemption you should become subject to the Workers Range_ Hr,�t,7 D W
Compensation provisions of the Labor Code you must forth Oven _ Dr 1.P1 W M — ADDRESS
with comply with such provisions or this permit shall be Top _ FAU W H —
deemed revoked Hood Fan :y Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp `_ Room Air Cond - REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PRO CE BY
and Professions Code and my license is in full force and effect Power Apparatus& Large Appliances �` !(r CL
i Size & Type HP KW KVA or KVAR Ub Q
License Number Lic Class Up to 1 Incl FINAL - tJ
Over 1 to 10 Incl DATE VALI TION O
Contractor Date
Over 10 to 50 Incl FINA V
I am exempt under Sec Over 50 to 100 Inc BY W
CL
B &P C for this reason Over 100 Z
Date Services Swbd MCC& Panelboards ►
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V
#�4 3 Q 4
SINGLE FAMILY
o 0 0 0 0
Temp Power Pole &Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I o o l 9 7 5 -
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 1 9 7 5 5=
Professions Code) o 0 0
�. I as owner of the property will do the work and the Misc Conduits&Conductors - Q 3,27-. 86
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , Y
7044 Business and Professions Code) -
CONSTRUCTION LENDING AGENCY
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)
(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 authorize representatives of this County to enter upon
the Above mentioned property for inspecjtion pur oses
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of ermine ate