HomeMy Public PortalAbout6027 CAMELLIA AVE_Electrical__ WORKERS'that CO"aN nO" °�"°" 7&kW � APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to seH �
Insure, or a eertificate.of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.) I
Poky No.-F-1�44-Company :rA/W 14 0MI POR APPUCAW TO Fu IN -013
ADDRESS Li,1
o Certified copy Is hereby furnlshed. New Residential Bldg:. & Pools EACH NO. FEE
❑Certified copy Is filed with the county building Inspec- 1 8 2-Family, Sq. Fl. � $ _ $ LOCALITY C
tion deportment. Multi-family Sq. Ft. 1,01 NEAREST
Residential Swimming Pools CRO55 G
ER OR
Date-7 1 D Applicant 1.0!hl �111a lit 4 N
'i/ RM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' X554
COMPENSATION INSURANCE Outlets: Rec Light Sw._
First 20
(This section need not be completed ff the work involved by Total No. Additional CITY I. No. r
the permit Is for one hundred dollars (;100)or less.)
I certify that In the performance of the work for which this PUNPLAN HES
permit Is Issued, I shall not employ any Person In any manner • Ughting Fixtures First 20 ADDRESS
to as to become subject to the Workers Compensation Laws.
Additional
Total No._ CITY Tel. No.
Date - - WD Applicant 1-DA3 Fixed Appliances Not Over 1 HP PBMlT
NOTICE TO APPLI : 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 —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CITY I. No
n
LICENSED CONTRACTORS DECLARATIONder Dlyp, — Room Air Cond. — REGI. NUMBER r S4 Class. (�'-/(�
I hereby affirm that I am licensed unprovisions of Chopter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PBY d
ct
and Professions Code,and my license Is In full force and effe .
Size &Type HP, KW, KVA, or KVAR O
License Number��.LIc. Class d-19 Up to 1 Incl. I FINAL
Over 1 to 10 Incl. DATE VALIDATION IM
Contractor LQ#-1 F41 def nate O
ElOver 10 to 50 Incl. FINAL U
I am exempt under . Over 50 to 100 Inc. BY LL
B.BP.C. for this reason Over 100 d
Z
Services, Swbd., MCC& Panelboards ,
Z
Date: 0-200 Amp. Under 600 V
Signature Up-,N 44jj� L-3--r= 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V T
SINGFAMILY � 3307� 1031.CC
LE
HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances 1 ITM
I hereby affirm that I am exempt from the Contractors License Sign with One Branch Circuit
Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits TOTAL 103 - 0101
Professloni Code):
❑ 1, as owner of the property, will do the work and the Misc. Conduits 8 Conductors iQS�
structure Is not Intended or offered for sale(Sectlon 7041, Other (See Complete Fee Scheduled , CA*GE ■00
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a corutruction lending-Nency for M-OQ1 2/14/90
the performance of the work for which this permit Is Issued PERMIT FEE (Sub-Total) 8933D 1 AM O:21111
(Sec. 3097, Qv. C.).
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
Lender's Address
I cwllfy that I have read this application and state that the TOTAL FEE
above Information la 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 REVEIME FOR L"LANATORY LANGUAGE
Signature of Permittee Dat6