HomeMy Public PortalAbout6267 AVON AVE_Electrical_12/5/1989_outlets, light fixtures, power apparatus 1
WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that'I'have a certificate of consent to self' CE 8066
,insure, or a certificate of Wbekers' C6mpensotion.Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
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. & Pools EACH NO. FEE ADDRESS V (r
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST. 1 DA�1J'O^
Date Applicant OWNER OR
FIRM NAME G.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec LightSw. MAIL tt�� /�/
COMPENSATION INSURANCE ADDRESS �! 3O �YP14C4 TT
First 20
(This section need not be completed if the work involved by Total No. Additional CITY�/#j'Y /y1�1j�/Q Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I 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 Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No._� CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of / APPLICATION
Exemption, you should become subject to the Workers' Range_ Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- Oven Dryer L 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
I hereby affirm that I am licensed under provisions of Chapter 9 � REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCE 4DWI�_ >_
and Professions Code,and my license is in full force and effect. D CL
Size & Type HP, KW, KVA, or KVAR i Q
License Number Lic. Class Up to 1 Incl. JBY
AL U
Contractor Date Over 1 to 10 Incl. TE VALIDATION cc
OOver 10 to 50 Incl. NAL 0
I am exempt under Sec. Over 50 to 100 Inc. 74
LLI
B.&P.C. for this reason Over 100 IdQ t1
Date: Services, Swbd., MCC & Panelboards Z
Z
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
ElExemption 1000 Amp. or Over 600 V
Exemption for Req. Maint. Elect.
SINGLE FAMILY 2
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances ''
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ACCTna
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits J�? 40.75
Professions Code):
MI, as owner of the property, will do the work and the Misc. Conduits&Conductors f ITEM
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— TOTAL 40 o7-_.s, t.
Business and Profess ions.Code). CHECK 40.75CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for `CHANGE .00
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE i.,( `� � 83r.,
Lender's Name p� ..1.��1�"'�V�i ��l :r�s:?r
PERMIT ISSUING FEE (�J
Lender's Address i289 1 PM121°C14
1 certify that I have read this application and state that the TOTAL FEE A()7 d
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-inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Os
Signature of P tree at