Loading...
HomeMy Public PortalAbout4812 CLOVERLY AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR LECTRICAPERMIT O I hereby affirm that I have a' c6rti cote of consent`to self CE 8066 insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES F PUBLIC WORKS or a certified copy thereof (Sec. 3600, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB r 2 C'Lti+ti��',QL FICertified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS FCertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST � / . Residential Swimming Pools OWNER CROSSSOR X0 141 ���L Date Applicant 'r ��p :+ �p FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec/Y—Light ` Sw.r MAIL COMPENSATION INSURANCE First 20 Oa ADDRESS (This section need not be completed if the work involved by Total No.�L Additional CITY Tel. No. the permit is for one hundred dollars ($100)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 erson in any manner so as to become subject to the W rs om n Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date ���� Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Cert' icate of y — Exemption, you should become subject to the Workers' Range X_ HeaterD.W APPLICATION 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 Tel. No. LICENSED CONTRACTORS DECLARATION o LICENSE OR Disp. — Room �r Cond. Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT O, PRO E BY a and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR 0 License Number Lic. Class Up to 1 Incl. FINAL DATE t2 Over 1 to 10 Incl. VALIDATION 0 Contractor Date l Over 10 to 50 Inc. U F-1 FINAL I am exempt under Sec. Over 50 to 100 Inc. BY LLl B.&P.C. for this reason Over 100 �200m C& Panelboards Date: Z nder 600 V Signature 201 - 1000 Amp. Under 600 V Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit i a I hereby affirm that I am exempt from the Contractor's License -4C-CT} nT Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3307 � .- Professions Code): I �as owner of the property, will do the work and the Misc. Conduits&Conductors }iMti structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ ► TOTAL 77m60 Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 1 n 601 1 hereby affirm that there is a construction lending agency forEi; qr. the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) UE (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name 0 il:;�i_ 011011 i 4/ ix1 j PERMIT ISSUING FEE N 4 o :�. Lender's Address r .131. _r I certify that I have read this application and state that the TOTAL FEE �'o 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 a - ntio �roper�ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ~ ©s Signature of Permittee Date