HomeMy Public PortalAbout5922 BURTON AVE_Electrical__ reWOSKER'SSATION DECLARATION 76A669DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT u
I he (iy affirm That Ihaveave a a certificate of consent to self insure, 20-001
or,a certificate of Whrker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLJC WORKS BUILDING AND SAFETY DIV.
copy thereof(SecT. 3800 Lab. C.)
Policy No. JG� Company A{ 9 FOR APPLICANT TO FILL IN ADO'08flESS ZZ ,[JUrIo YX
F, Certified cap Is hereby furnished. /0 a/'/�P - EACH NO. FEE -
Y Y New Residential Bldgs.&Pools rr�� LOCA CA
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Certified copy is filed with the count building inspection 1 &2-Family,Sq.Ft. 31 01 $ — S. 2. "• C
Y q p NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date ]�h I I I Z Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS'.., Outlets:Rec. LightSwOWNER ORLG
COMPENSATION INSURANCE _ ._ FIRM ME
O
.' ,(
(This settlor enot Total No. First 20 MAIL Additional ADDRESS be completed if the work involved by the 6 (�,h St `7
permit is for one
he untlred dollars($700)or less.) - /
I certify that in the performance of the work for which this permit CITY Tel,No. 'Ig3_96�Z
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 PLAN CHECK
1 P 9 APPLICANT
• Total No Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption;you should become subject to the Workers' Compensation 1 TO 10 INCLUSIVE EACH _
provisions of the Labor Code, you must forthwith comply with such 11 T040INCLUSIVE EACH PERMIT
APPLICANT
provisions or,this permit shall be CONTRACTORS
revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSEDDCONensed under
provisions
- - ADDRESS ' �(��
I hereby affirm that 1 am licensed under provisions of Chapter 9 150R 20A,208V T0277V LIGHTING EACH d
(commencing with Section 7000) of Division 3 of the Business and . CITY �-�"�� Tel.No. 1_��A 0
Processions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP T03HP LICENSE OR / r��� Class C_L Ila
q^ Power Apparatus&Large Appliances REG.NUMBER b"1 O
60' I T'r C-LO Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY ~
License Number— Lic.Class p yp��
Up to 3 Incl. - �QO
ContractorCRK�— C.«-G t C-Date L( cr� Over 3 to 10 Incl.Over 10 to 50 Ind. DATE �r_ (/)
EJ exempt under Sec. Over 50 to 100 Incl 1�`�9* �- VALIDATIONS ?
Over 100 - _ FINAL I
B.&P.C.for this reason BY
Services,Swbd..MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.,Under 600 V -
❑ - Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect. p
SINGLE FAMILY Temp.Power Pole&Appurtenances \-7,9 ;vf,1:T.
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
S.
I hereby affirm that I am exempt from the Contractor's License Law _ _ _ jrl.
for the following reason (Section 7031.5. Business and Professions Additional Sign Branch Circuits ._IvLI% .� ti,,:=•_,b
Code):
yr�_
❑ Misr.Conduits&Conductors
I,as owner of the property,will Bothe work and the structure .-t
is not intentled or offered for sale (Section 7044, Business Other(See Complete Fee Schedule), D f AL 5 S:a:_
and Professions Code). - - ' `L'�•In
CONSTRUCTION LENDING AGENCY` .- ._ _ - __. - :. _ -
:11hk'{� 11 (
I hereby affirm that (here is a construction lending agency for the / L��ITu'I�;i- _-
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total). Cl�&7''
Civ.C.) —
PIAN CHECKING FEE1-'i':;_I13 _t;i 11,4`.
Lender's Name .
PERMIT ISSUING FEELender's Address
Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws regulating Electricalwiring, and hereby authorize
representatives of this County to enter upon the above-mentioned � --
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'S71I��ja
SIGNATURE 9ei`(T LI N OR AGENT _ DATE