HomeMy Public PortalAbout5008 CAMELLIA AVE_Electrical__ Y W012KERS'COMPENSATIONDECLARATION 76 8066 12-B01 63
CE 8APPLICATION FOR ELECTRICAL. PERMIT -
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANG LES �I WING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy therppe f(Sec. 3800 Lab. C.)
p.7 "4 S FOR APPLICANT TO FILL IN JOB /� ,/
Policy No o any—py/LO Lr'�tSUA�T� EACH NO. FEE ADD RE S�� � C,011t,&Z
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-FamilY.Sq. Ft. $ — $ LOCALITY r�—JYfiO E G/
—
Certified copy is filed with the county building inspection Multi-family Sq. Ft. NEARESTCROSS ST
department.
_�' Residential Swimming Pools OWNER OR
Date Applicant Outlets: Rer{�Light CJ " "' ,t t FIRM NAME g7W0p���/T/r7'•'fE�J
Sw. 5v G MAIL
ADDRESS ..70
�, First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. / Additional CITY /jrj/jjJ��r/�¢ Tel No.
COMPENSATION INSURANCE }
r PLAN CHECK tL
(This section need not be completed if the work involved SI.I D APPLICANT
Fixtures First20
by the permit is for one hundred dollars ($100) or less.) Lighting io ADDRESS U
Total No. �' Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. O
permit is issued, 1 shall not employ any person in any manner PERMIT /�' �^ L)
so as to become subject to the Workers' Compensation Laws. Rangel Heater—D.W. APPLICANTIL
/� G/�i��G W
Oven _ Dryer_W.M. ADDRESS rA
Date Applicant Top _ FAU _W.H. Z
Hood _ Fan L_Other _ �n1 CITY �fi�/J��i'12 Tel
NOTICE TO APPLICANT: If, after making this Certificate of Dis .I.SL' (J LICENSE OR +�' ion
p. '�, Room Air Cond._ REG. NUM BE F{.1�aI Class C� 0
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you most forth- Power Apparatus& Large Appliances DISTRICT PRQCEgtED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP, KW, KVA,or KVAR
Up to 1 Incl.
FINAL
Over 1 to 101ocl. DATE 4 —� 3-�( VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL n
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY
ness and Professions Code, and my license is in full force and V/I
effect. ••������JJ��// Services 7 7
License Number rv� Lic. Class ��O 0-200 Amp. Under 600 V •� � ) •�/ /
,104 /�y/� 207-7000 Amp.Under r 0 V
Contractor ate_ Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp, Power Pole& Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): 3 2 Z 6 A
Misc.Conduits&Conductors
❑ 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— # o ° ° o oz
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2 ° ° 3850
I hereby affirm that there is a construction lending agencv
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel 202-80
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
above information is correct. 1 agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby au hortze representatives of this County to enter upon
the -menti o d properr inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee at�