HomeMy Public PortalAbout6025 CAMELLIA AVE_Electrical__r
woCOMPENSATION DECLARATION . 2D-0019 DP" APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirmrm that I have a certificate of consent to self CE
Insure, or a certificate of Worken' Compeniatlon Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Pity No – Il 11�Company1r111��Q11jT. POR APPLICANT TO I'RL IN JOB
,2
Certified copy Is hereby furnished. New Residential Bldgs. 8 Pools EACH NO.
CRCGS Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. 7,9x, ; — S LOCALITY
Fitton department. Multi-family Sq. Ft. _ T
CROaS ST.
Date Appllcant I.MJ WLA Residential Swimming Pools
OWNFR OR
IRM NAME
CERTIFICA OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._,_ MAIL
COMPENSATION INSURANCE
Firs 20
(This section need not be completed 1f the work Involved by Total No. Additional CITY Tel.
the permit is for one hundred dollars (=160)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 Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers Compensation Laws:
Total No. Additional C1 TY Tel. No.
Date – 1 "'IV Applicant LL») HUA LIE&
Fixed Appliances Not Qver 1 HP PERMIT
NOTICE TO APPLI : If, after making this Certificate of APPL�� -17
Exemption:, you should become subject to the Worker: PangP— Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
cl"med revoked. CIN Tel. No.
LICENSED CONTRACTORS DECLARATION Hood — Fon —Oth*r— Li ORI hereby affirm that I am licensed under provlsioro of Chapter 9 Dlap. — Room Air Cond. — NUMBER Ck3sa
(commencing with Section 7000}af Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT . n �BV >_
and Professions Code,and my license is In full force and effect. U
Size 8 Type HP, KW, KVA, or KVAR 1 O
Ucense Number r4 Llc. Class Up to 1 Incl. FINAL VV
D Over 1 to 10 Incl. DATE VALIDATION O
Contractor 14241 RMA 14!1-- Date l `4 Over 10 to 50 Incl. FINAL 0 Ir–
ElI am exempt under Sec. Over 50 to 100 Inc. BY LU
B.BP.C. for this reason Over 100 d
U1
Servlcea, Swbd., MCC 8 Panelboards Z
Date: 0-200 Amp. Under 600 V
Opp-
Signature L.&A-1 "11A. P-Acs- 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Malnt.Elect. +7
a
SINGLE FAMILY Temp. Power Pole 8 AppurtenanceA
HOME OWNER-BUILDER DECLARATION) s
Sign with One Branch Circuit .T
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Additlonal Sign Branch Circuits 3307
Profeuions Code): 1 ITM
I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
structure Is not Intended or offered for sale(Section 7041, Other (See Complete Fee Schedule. TOTAL 102-50
Business and Professions Code). ' �Ci 102-90
CONSTRUCTION LENDING AGENCY 04ANGE .I0
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued PERMIT FEE (Sub-Total)
(Sec. 3097, Cly. C_).
PLAN CHECKING FEE OC1C&-"l 2/14/90
Lender's Name PERMIT ISSUING FEE 3931 1 Ali 8:r-
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
above Information Is correct. I agree to comply with all County
ordlnances and State lawn regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for Inspection purposes. q�n
SEE REVERSE FOR EX]P AMATORY LANG1JAGE vd
Lyi'" f.
S1gnature of Permltfee Dalb