HomeMy Public PortalAbout6267 AVON AVE_Electrical_4/6/1989_outlets, lights, switches WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATBON FOR ELECTRICAL PERMIT
j�;reby a'�irm that I'have a certificate of consent to self insure, CE-806G [, I
ora certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY U
copy thereof(Sec.3800,Lab. )
1''I'
Policy NOS/rfl� COmpafly FOR APPLICANT TO FILL IN JOB' },,
Certified copy is hereby furnished. New Residential Bldgs.& Pools
EACH NO. FEE ADDRESS vOW
ACertified copy is-filed with the county" building inspection 1 & 2-Family,Sq.Ft. $ $ LOCALITY e� lis —�✓
department. Multi-family Sq.Ft. — NEAREST
CROSS ST. (nJ�V �Ljf
Date �r Applicant Residential Swimming Pools OWNER OR \' A
IL NAME .` R
CERTIFICATE OF EXEMPTION FROM WORKERS' M MAILv �
COMPENSATION INSURANCE Outlets:Rec Light Sw. — ADDRESS
1
(This section need not be completed if the work involved by the First 20 ; CITY CA 144 &5 Tel.No),
permit is for one hundred dollars ($100)or less.) Total No Additional`
I certify that in the performance of the work for which this permit k PLAN
CHECK +�
APPLICANT
is issued, I shall not employ
p y an y person in any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Z) A LAs 1,nn5 )fZ
Additional
Total No. CITY" Tel.No.
Date Applicant (7 S
NOTICE TO APPLICANT: If, after• making this Certificate of Fixed Appliances Not Over 1 HP PERMIT s
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT '( C19L41 --,l
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer W.M._ ADDRESS � Z1 A LA-S ' tuy,IAS )Z
provisions or LICENSED shall W CONTRACTORS DECLARATION Hood — Fan H
CITY Tel.No.Z� !J t`~
s
Other_
I hereby affirm that I am licensed under provisions of Chapter 9 3 Disp. — Room Air Cond. LICENSE OR P �J' /� ;��� Clas ►jCj
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER P J
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PRQe SS D BY
J `�� Size& Type HP,KW,KVA,or KVAR, . Q 0
License Number - IS u Yb � �� Lic.Class ���0 Up to 1 Incl. FINAL
0
Over 1 to 10 Incl DATE VALIDATION 0
Contractor Fi�� ? � V�p�e' `d �A
Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. gy L J
B.&P.C. for this reason Over 100 0.'
Services,Swbd.,MCC& Panelboards
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp. Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit f,r'•,.17
I 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 r^ "G
Code):
❑ Misc.Conduits& Conductors
I,as owner of the property,will do the work and the structure +-�,---n �•
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ® a ._u
"' '' 7
and Professions Code). �,+h`. -7a 5
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(Sec.3097, PERMIT FEE- (Sub-Total)
Civ.C.).
PLAN,CHECKING FEE `I —-# € 4/ Oli 8`9
Lender's Name ^r S r ,)
PERMIT ISSUING FEE ',"
D 1'
Lender's Address
1 certify that I have read this application and state that the above TOTAL FEE i
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 inspection purposes.
� 6 v - SEE REVERSE FOR EXPLANATORY LANGUAGE -
6k"
Sign ture of Permittee Date