HomeMy Public PortalAbout4527 CLOVERLY AVE_Electrical__ 'Y°�`° 'CGMPENSAMON DECLARATION CE-BOO '°'&' APPLICAnON FOR ELECTRICAL PERMIT
1 hereby eff m that I have a cwtffloate o( conowd to eeff kvue, CE�beG
,a a oertlfloate of Woriaera' Comp atbn Ineurano% or a oer-Iffled COUNTY OF LOS ANGELES BUILDING AND.SAFETY
copy ftwed(Seo.3600•Lab. C.) ,�,CJY
Ponvy Na 738 ZW. terry --'> w FM AST To FLLIN Z'-7 �It�ut�rc 1
Fl- Certtfled py i.hereby furrid d DFEti8
Now Reasdentlel Bldgs.8 Foote. F�,ca•I No. FEE_ AD
LA At�-e-,
Gertftfed copy fa flied with-the county.bdiding hap 1 a 2-Family,$q.Ft 3 T �Ocu1rY 'T��v. f Q Gi
department Mufti-fart*Sq.Ft_ ai(ms-r LoweL �qz✓,sA
Date pppiben{ Reeid6ntieiL9�wtNrri1p Pooh CWNER
NAWQLk f C.'A-k �4 LJ\01
C=F1 COMPENSATION INSURANCE WORKERS', Rl fc � �'� � ADDbbREs8
(This section newel not be cbmpked t1 the work FrwoNed by the c Ad t 20 CRS
pern-A Is for one l}undred dol la re 100)or lass.) Tbtal Na�� Additlonal
I oertify that In the perbrmanoe of,the;work for which thle pwTr ft App Pt'V t
as Leeiied, I &hall nct employ any,persw In.arry manner eo as to
become a�)eot to bie'Wbfke{s'Coln nsaiion LeveAdditlocial
Lb ro Fbcturee•r Fiat 2a' ApDt�E38 2�J
Total Na r - G FY VOC> NoV4 f
Dabs Fbaed Appparm8 Not Over 1 HP113
•�-�'
NOTICE ,TTI, CANT: if, OW nwkh g thfe 0( APEEP C�f 1T n}. ,U
F- ,.y%&hand bedome aub)ect to the Worhefis'Cortpeneatlon Fie— "mW_— D.W. T
pfov(elone of the Labor Codd,you Alot forUwAth coff#y with much Oven Dyer T W.M-_ ADDRESS
Ppb;or pwTnft&hell be dgerYied revoked Tog FAU WA CITY' StAJd(LQTeI Na
ED CONTRACTORS FC✓_ARQPON Food Fon Other_
I `hereby afflrmOvqa 1.arrr lbeneed under provhforb of Chapter 9 DlW. _ Roan Air Coml. aetrCENSE OR �.� CwL
-(oommerlo6g with Section 7000) cf'D1A& n 3 of the suelnee& and .
Profession Code,end.'my llcenee la In full force and elect Power.Apparahre 8 Large Appilancee
Jr Z ZD Stye.s Type HP,KW,KA or KVAR �/0
LJoerrae tkcnber , U0.Clea&- Up to 1 Ind. FINAL V
^ Over 1 to 10 1ncL DATE 1 Z
over 1Q to 60 tnd. •
FrLAL 7
ElI am exempt under Seo. fiver 60 m 1-00 ho.
BAR.C.for this reason over 100
Servbee,Swbd,MOC S Panefboerds ,
0-200 Amp.Under 600 V
Sonatum 201 - 1000 Amp.Under 800 V
ever 1000 Amp.or Oyer 600 V
Exemption for Red,Mmint Elect -
SINGLE FAMILY Temp•Power Pole d APPiatenebcas
HOME CJWNER-BUILDER DECLARATION Sign with One Branch Giroiff _. _ ACCT■tr
I hereby aMrm that I am exempt from the Contr9do4'e Uoenee Lew
for the 1olbwring reseon(Seotbn 703 t6, antnew and Protamabo& t Addm«,al Sign Branch Cttrzfte ' _Y. X07 15.00
code): '• •'' • ' • - 1 IT .
El, I,as owner of the proparty�wffl do the work and the atuot re M1ea Condufte 8 Conductbre �tl5
la not fntmxW or--offered for eoie (Sec: n 7044• Buskwu Other(See Comdieta Fee Schedule) TOTAL 15.00
and R&a&abn:8 Code). (t; .15 Of
CONSTRUCTION LENDNG AGENCY 44 C 00
I hereby alftrm that ter
he b a oonetruotien
on ler&ng agcy for the _ L�3i71L •
performance of the w"for wNoh thte permit Is Issued(Sea 3007; PERMIT FEE (Sub-Tda1) -
Ctv.C}. r
PLAN CHECKM.FFE 11tiMJzrt�u} 111 2/89
Lander&Name ~ PERMIT ISSUING FEIN 6537 1PM 12t0¢
Lenders Addreea
I ow fy thab l have read this applbatbn and state thet the.above . . TOS SEE
Vdorr WJw la correct, I agree to comply wtth all County ordnanoee
and State laws requlattng Eleohi wMng, and t»reby aufte e
repreeerntativvee of thle County to artier mon the above mentioned
SEE REVERSE F,EXPLAN11`1 iJiNGUAOE
0
Signature of Perm bae