HomeMy Public PortalAbout4503 FIESTA AVE_Electrical_9/9/1983_APPLIANCE FIXTURE WORKERS COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT"
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
o_;Q�cer1Lf����t��f (Sec 380����
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
Y 9
1 & 2 Family S Ft $ _ $ LOCALITY �'pG f= C,j
Certified copy ,s filed with the county building ,nspec /j
tion department Multi family Sq Ft NEAREST AMIMA74 p /1 /)/►
CROSS ST YYCC==..GG-- aI7
Residential Swimming Pools OWNER OR
Date- Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Li ht Sw_ MAIL JD
COMPENSATION INSURANCE g ADDRESS rn F �&
�
is section neenot completed if the work involved b First 20 �
(Thectd t b
p y Total No Additional CITY ��,� _ Tel No
the permit is for one hundred dollars ($100)or less )
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT
permit 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 ADDRESS
Total No Additional
CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESS �C
with comply with such;provisions or this permit shall be Top — FAU —W H
deemed revoked I Hood _ Fan _Otherx / CITY Tel No ��z
LICENSED CONTRACTORS DECLARATION Dis4ConLICENSE OR r�
I hereby affirm that I am licensed under provisions of Chapter 9 RooA,rL30 :ZZ0Q E•r REG NUMBER 3��J� Class �f Q
(commencing with Section 7000) of Division 3 of the Business P DISTRICT PROCESSED BY
and Professions Code and m license is in full force and effect P Ances
Y ,z y e KW KVA or KVAR 0
License Numberc-W��Lic Class - _ p to 1 Incl FINAL V
�' p DATE
d ��C�� �` 5{Z Over 1 to 10 Incl VALIDATION 0
Contractor � ante .-!+ Over O10 to 50 Incl
❑ FINAL U
I am exempt under Sec Over 50 to 100 Inc BY W
Over 100 - CA
B &P C for this reason �t� ���
Date ServicesSwbd MCC & Panelboards
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Ma,nt 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
Professions Code) -
❑ I as owner of the property will do the work and the M,sc Conduits& Conduct is
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for 2 5 0 61 A
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) -
(Sec 3097 Civ C ) # o o 0 o,o 2
PLAN CHECKING FEE -
Lender s Name
PERMIT ISSUING FEE 10 12 - - 2900
Lender s Address ° 0 0 2 9 0 0 c=i
I certify that I have read this application and state that the TOTAL FEE t
ave information is correct I agree to comply with all County 909-83
ordina and St to laws regulating Electrical wiring and
hereby out raze r pre s of this County to enter upon
entio d rop t ection purposses SEE REVERSE FOR EXPLANATORY LANGUAGE
I /a
Signature of Perm,tee Date