HomeMy Public PortalAbout5930 CAMELLIA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 764lo,al APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self (E�)0606 G
Insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thpreof (Sec. 3800, Lamb. C.)
Po❑Ilcy IN:3 Company �7G7r � raj FDR APMJCAM TO FLL IN
Certified copy Is hereby furnlshpd. New Residential Bldgs. R Pools EACH NO. FEE ADORESS
3�
Certlfled copy Is flied with the county building inspec- I � 2-Family, Sq. Ft. _ _ $ fCXALrry
tion de meet. Multi-family Sq. Ft. rT
ST.
Dare 3 Appll� Residential Swimming Pools -OWNER TOR
.
.01 FIRM NAME
CERTIFICATE OF bCEMPTION WOR 5' Outlets: Rec ight Sw. L 3 —
COMPENSATION INSURANCE' First 20
(This seciton need not be c*rnpleled If the work Involred by Total No Additional Cl I. No.,;) 33
the permlit 14 for ohe hundred dollprs (:100)of leu.)
I certify that In The perf6rmarjce of the work for which this APPLICANTPLAN CHECK Z
perrult Is Issued, I shall not employ any pCwlon In ciny manner
to as to become subleot to the Workers Compensatlon Laws. Lighting Fixtures First 20 ADDRESS
Additional 9
Total No. CITY To 1. No.
Date A'4, aftt Fixed Appliances Not Over I HP PERWT y
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, y6u sh6uld becomq subject to the Workers' 'kange— Heater_D.W. — !1
Compensation provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS fy51
,
with comply with such provlslons or this permlt. shall be Top T kU —W.IJ. CfTY T•I.No.S f f1
deemed revoked. Hood _fan _Other_
LICENSED CONTRACTORS DECLARATION OR
I heraby affirm that I am licensed unoer provisions of Chapter 9 Dlsp. — Roorri AIF Cont, REG NUMBER J CIasa.��/f}-
(commencing with Section 7000)of Division 3 of the Businew power Apparatus&Large Appl lances DISTRICT NO. BY }
and Professions Code,,and my license is In full-force and effect.
�`' / 77� LIG Class '4 f� Size 8 Type HP, KW, KVA, or KVAR FINAL O
License Number Up to 1 Incl. V
�—C f S � Over I to 10 Incl. DATE VA13DA170M 0
Contractor Over 10 to 50 Incl.
FINAL
I am exempt under Sec. .(Suer 50 to 100 Inc. BY
B.BP.C. for this reason Over 100
Date:
Services, Swbd., MCC 8 Panelboards ►
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Undpr 600 V
Over 1000 Amp. or Over 600 V
Exemption for Rep. Mafrit. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances �lr5?;r
HOME OWNER-BUILDER DECLARATION Sign with One Brdnch Circuit
I hereby affirm that I am exempt from the Contractors License
Low for the following reason (Section 7031.5, Business end Addltion4t Sign ganef Circuits
PPr}rofewlons Code): 2 2a50
U I, as owner of the will do the work and the MAsc. Conduits 8 Conductors
� Other See Complete Fee Schedule)— ,
attucture Is not Intended or offered for sale (Section �., p - ) -.- •e o 0 25,5 0 6
70", Business and Professlons Code).
CONSTRUCTION LENDING AGENCY 0324-83
1 hereby affirm that there is a gonWyction lending agency for
the performance of the work for which this permit Is Issued PERMIT FEE (Sub-Totao
(Sec. 3097, Civ. C.).
PLAN CHECKING Fid
Lenders Name
PERMIT ISSUING FEE
Lend,ers Address
I certify that I have read this application and state that the TOTAL FEE
gbove inform¢tlon Is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representortives of this County to enter upon
the above-mentioned property for Inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE
7 ^ ?3
'SigaOdre of ee Date