HomeMy Public PortalAbout6035 CAMELLIA AVE_Electrical__ 7
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COMPENSATION DECLARATION ,&-.W DPW 3/57 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self 1��
Insure, or a cafttficate.of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certffled copy thereof (Sec. 3800, Lab. C.)
Po Icy No. le-11 �3 Company FOR APPLICANT TO RLL IN e /�
Certified copy Is hereby fumished. New Residential Bldgs. 8 P NO. FEE ADDRESS
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Certified copy Is filed with the county bullding-Inspec- 1 8 2-Family, Sq. Ft. / $ — $ 113 LOCALITY
ED
tion department. Multi-family Sq. Ft. NEAREST
Residential SwimmingPools ' CROSS
Date goApplicant 1110 ,f�� /_iZE
• IRlr+NAME D . IYiH
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Ught Sw._ MAIL ��y
COMPENSATIONFirst 20
NINSURANCE ADDRESS O. Yli
(This section need not be conp6ted N the work Involved by Total No. Additional CIN
the permit Is for one hundred dollen ($100)or.less.) PLAN OiECX
I certify that In the performance of the work for which this APPLICANT
permit Is Issued, I shall not employ any person In any manner Lighting Fixtures First 20 ADDRESS
to as to become subject to the Workers'Compensation Laws, g g
Additional
Total No. CIN Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP pET
NOTICE TO APPLICANT: If, after.making this Certificate of e— Heater—D.W. APPUCATKXJ
Exemption, you should become subject to the Workers' ng
Compensation provisions of the Labor Code, you mutt forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions cr this permit shad be Top — FAU W.H. —
deemed rev6ked. Hood — Fan —Other— CIN Te. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am Ilcenaed_under provisions of Chapter 9 Di..sp. — Room Air Cond. RIG NUMBER -r Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT N . BY
and Professions Code,and my license la In full force and effect. a
Size 8 Type HP, KW, KVA, or KVAR 0
License Number � u� ^Llc. Clan ���� Up to 1 Incl. FINAL -
0
Over ver 1 to 10 Incl. DATE VALIDATION �
Contractor" HVA --2-1 Ovef 10 to 50 Incl. FINAL U
Elam exempt undef Sec. Over 50 to 100 Inc. BY W
B.BP.C, for this reason Over 100 d
Servlces, Swzbd., MCC 8 Panelboards W
brit°' 0-200 Amp. Under 600 V
Signature Cetj,) 141LA LAS 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Malnt. Elect.
SINGLE FAMILY Temp, Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION a
I hereby affirm that I am exempt from the Contractof's License Sign with One$ranch Circuit AC.GT.r
Law for the following reason (Section 7034-.5, Business and Additional Sign Branch Circuits 3307 103.00
Professions Code): 1 ITEM
❑ 1, as.owner of the property, will do'the work and the Misc. Conduits 8.Conductors
structure Is not Intended or offered for sale(Section 7044, Other (See Complete Fee Scheduled ® TOTAL 103 -00
Business and Prafessions Code). .�U
CONSTRUCTION LENDING AGENCY
I heraby.affirm that there Is a construction lending agency for C#MG •W
the performance of the work for which this permit Is Issued PERMIT FEE (Sub-Total)
(Sec. 3097, Cly. C.).
PIAN CHECKING FEE OX&'M 1 2/14/90
Lender's Name PERMIT ISSUING FEE 7 1 Ali 8:27
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
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the abovementloned property for Inspection purposes.
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