HomeMy Public PortalAbout5109 DALEVIEW AVE_Electrical_7/15/1983_OUTLETS WORKERS'COMPENSATION DECLARATION - 76A663 10/81 APPLICATION
PPL IC TION FOR ELECTRICAL
PERMIT
I .hereby affirm that I hove a certificate of consent to self GE-8066 PY `IL P9 Iltl IL is R 'b P1lL YHA l '•
'i insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
'or a certified copy thereof (Sec. 3800, Lab. C. _
PolicyNo. Com an `r ,{ 1 + •"� FOR APPLICANT.TO FILL JOB i" CG' J "f
P Y
❑ Certified co is hereby furnished. EACH NO, FEE ADDRESS;.,_)1- �j•
PY Y , New Residential Bldgs. & Pools _
1❑ Certified copy is filed with the county building inspec- 18.2-Family,Sq. Ft. • $ — $ t LOCALITY
° Z tion department. Multi-family Sq. Ft. — A NEAREST �
E (CROSS ST. !n '
' Residential Swimming Pools
Date Applicant -
FIWNER.OR RM NAME r V t c.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets RecLighl
Yr - :... MAIL
( _ r - r -
COMPENSATION INSURANCE Sw. /,+ ADDRESS% ,._,
(This section need:not.be completed if the work involved by- Total No. First.20 -.•x-- CITY .„. . f ,, Tel No
1
the permit is for one hundreddollars ($100)or less.) -Additional
PLAN CHECK:
'.I certify that in Iherperformance of the work for which this _ � APPLICANT44
permitis issued,'l shall not'employ any person in any manner" - -
so 6s'to become subject to the Workers' Compensation Laws: Lighting Fixtures First 20 ADDRESS
f (" Total No. Additional f ..
CITY ` Tel No
Date ' Applicant - FixedA licences Not Over 1'HE -
� � � � PP r PERMIT ' r
r NOTICE TO APPLICANT: If, after making this Certificate of W APPLICANT F' +{,..: ¢ jP - u.. r .j'
Exemption, you should become subject to the Workers' Range— Heater_D.W. "
i• Compensation provisions of the Labor Code; you must forth- Oven _ Dryer — W.M._ ADDRESS
with comply with such provisions or this permit shall be Top' FAU —W.H. t y f t C
deemed revoked. i CITY ��P 4_1 �7 x(�,;^y Tel No 1d,•+ !.y"
r` s LICENSED'CONTRACTORS DECLARATION Hood _ Fan _ Other_' 1 - -_
SE OR
hereby affirm that am licensed under provisions of Chapter 9 Disp.r_ Room Air Cond. REG LICENNUMBER
'`. ,( ..,..i Class
(commencing with Section 7000) of Division 3 of the BusinessPower Appdratus'8 AppliancesLarge DISTRICT NO. PROCESSED BY a
�.
and Professions Code and my license is in full force and effect. .- yr""" - %' � O
f
Site 8 Type HP, KW, KVA, or KVAR' ,.1 / rl-'$gyp.-r''✓/ r.�• V
F
License Number - ! '^'� h,_Class+ r Up to 1 Incl. - FINAL -
er, i. ( _ �, 'f� O 1 t 10 Icl. DATE ry
s Contractor +• ' Date Over o n
VALIDATION
❑ / Over 10 to SO Incl. FINAL
1 am.exempt under Sec. Over 50 to 100 Inc. BY Q
rOver 100 IX
Y B.BP.C..:for this reason . _ O
Services, Swbd., MCC 8 Ponelboords _ D Cc_
Date: 0 -200 Amp. Under 600 V
t{ Signature 201.- 1000 Amp. Under 600 V F-
❑ Over 1000 Amp. or Over 600'V,
!- Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances -/ r ,
HOMEOWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Brb nch Circuits {!la l;��,1� d�
Low for the following reason.(Section 7031.5, Business and �'-
'Professions Code):
❑ I, as owner of theproperty, - Misc. Conduits B,,Conductors
will do the work and the Com lute See
structure is .not intended or offered for sole (Section Other (, - p ,Fee Schedule)— jt 73 r,'T
� 7044, Business and Professions Code). ,
,. t
nn � -
CONSTRUCTION'LENDINGAGENCY
` 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.). - -
It
PERMIT
PLAN CHECKING FEE
` Lender's Name Yp _
y,... PERMIT ISSUING FEE
Lender'sAddress - -
( 1 certify that I have read this application and state shot the JTOTAL FEE
t dbowe;informotion 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 inspection purposes.Al
.SEE.REVERSE FOR EXPLANATORY LANGUAGE
-
Signature of Permittee" 'Date - -