HomeMy Public PortalAbout6028 CAMELLIA AVE_Electrical__ WQRKERS'COMPENSATION DECLARATION 2D-CO19DPW 3/97 APPLICATION FOR ELECTRICAL PERMIT
.) hereby'afflrm,that I have a certificate of consent to self
Insure; or a cerllflcate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 39D0�,
yL.ab. C.)
No P Company-zR
4m Rap t APFUC NT TO LL Tit ADDRESS
Vo2� '•
Certified copy Is beraby furnished. New Residential Bldgs. 8P EALH FEE
❑Certified copy Is filed with the county building Inspec- 1 8 2-Famlly, Sq. R. $ — $ LOCALITY
tion department. ), Multi-family Sq. Ft, NEAREST
CROSSDate licant A{/• ��
�LJ. ��G . Residential Swimming Pools OR
�
App ,/ FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw._ ADDRESS
First 20
(This section need not be completed If the work Involved by Total No. Additional CITY o
the parmlt Is for one hundred dollars (:100) or lass.) RAN❑-IECK
I certify that In the performance of the work for which this APPLICANT
permit Is Issued, I shall not employ any Person In any man Lighting Fixtures First 20 ADDRESS
so w to become subject to the Workers Compensat
Additional
Total No. CITY Tel. No.
Date Fixed Appliances Not Over 1 HP P92MlT
NOTICE TO APPU after making this Certificate of APPLICATION
Exemption, ould become subject to the Workers' Range— Heater—D.W.
Compen n provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS j
with amply with such provlslons or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CfTY S Tel, No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
Dlsp. — Room Air Cond. — REG. NUMBER ,S/Q 4zClass.
I hereby affirm that I am licensed under provisionsof Chapter 9
7,2
(commencing with Section 7000)of DIVIzIon 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. BY O}..
and Professions Code,and my license 4 In full force and effect. fJ
Size 8 Type HP, KW, KVA, or KVAR �CJ 0
License Number ���� 72-1.1c. Class C,-41C) Up to 1 Incl. FINAL U
a/,CW /;� & Y Over 1 to 10 Incl. DAA VAIJDATIOfI 0
Contractor T^��{/–G�� n^+e Over 10 to 50 Incl. FINAL { ~
❑ I am exempt under Sec. Over 50 to 100 Inc. BY ,�{I� 1V 7.
Over 100
B.BP.0 for this reason 1 ��C�= CL
Services, Swbd., MCC 8 Panelboarda
Data. 0-200 Amp. Under 600 V Ti!TFL 1.87 - 59
Signature 201 - 1000 Amp. Under 600 V C 1`'7 c�
CK U. -
Over 1000 Amp. or Over 600 V
❑ Exemption for Reg. Malnt. Elect. (A ,[E,!
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER TION
I her affirm t m exam 6m the Contractors License Sign with One Branch Circuit „�,/r y
Law�th owing reason (Section 7031.5, Business and Additional Sign Branch Circuits �rl�30 i 'J�� '"
Prof s Code): 1�4L 1 C:Y:
I, as owner of the property, will do the work the Misc. Conduits 8 Conductors
structure Is not Intended or offered for sal Ion 7Wd, Other (See Complete Fee'Schedule)_ ,
Business and Professions Code).
G AGENCY
I hereby tat there Is a construction lending agency for
the mance of the work for which this permit Is Issued PERMIT FEE (Sub-Total)
( 3097, Clv. C.
_
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE c,1
Lenders Address
I certify that I have read this application and state that the I TOTAL FEE
above Information Is correct. I agree to comply with all County
ordinances and State laws regulating E Ical wiring, and
hereby authorize epresent Ives of t unty to enter upon
the abov rty f pectlon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S natur `of Permits Date �s