HomeMy Public PortalAbout4924 DOREEN AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 75-563 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT {�
I hereby affirm that I have a certificate of consent to self insure, LJ
or a certificate of Workers Compensation Insurance, or acertified COUNTY OF LOS ANGELES BUILDING AND SAFETY
' /•P016yNO.� COmpahy FOR APPLICANT TO FILL IN - -JOB
F, Certified co Is hereb furnished. - EACH NO. FEE ADDRESS;
PY rY New Residential,Bldgsl& Pools ' - ..
, .r.' L $ — V LOCALITY - .•'G
Certified copy is filed with the,county building inspection 1 & 2-Family, Sq.Ft.
dep rtm0Multi-family Sq.FL
NEAREST -
`-�. ��•r . CROSS ST L(7 � � �<— Z U
Date Applicant
OJ ��/I Residential Swimming pools' OWNER OR
FIRM NAME " (7
CERTIFICATE OF EXEMPTION FROM WORKERS' _L ' MAIL -
Outle�s:Bee Light _ Sw,-
COMPENSATION INSURANCE. - ADDRESS
r First 20'-
(This section neetl not be completetl iF,ihe workinvolved by the � CITY T.I.No��,�,�
;permit Is for one hundred dollars ($100) or less.) _ Total No. Additional
,I Certify that in the'-perfo'rmapce Of the.workPLANwhich this permit PLAN CHECK
is issued,•I shall not employ any'person in any manner so as to APPLICANT
become'subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
/ Additional
- " Total No. r - - t CITY .. - Tel.No. .
Date Appk'* Fixed Appliances Not Over 1 HIP
NOTICE TO APPLICANT If" after making• this Certificate Of REKNIT E/ems /G,
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
'provisions'of the Labor Code, yo_u'must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit'Shall be deemed revoked. Top — FAU W.H. —
.LICENSED CONTRACTORS DECLARATION Hood Fan _, Other_ - CITY - •.L�y� T.I.
I hereby affirm that I am licensed antler provisions of Chapter 9 3 UCENSE OR
Disp. .Room Airbond. REG.NUMBER. S3
(commencing with Section 7000) of Division 3 of the Business and '
Professions Code,and my license is in full force and effect. .DISTRICT NOPR SED BY
Power Apparatus B,Large Appliances }'
� ��+ G/D Size 8 Type HP,KW,.KVA,or KVAR Q
License Number JlS I_ic.•Class V
- Up 1 Incl- FINAL _
/ J� Over 1 to 10 Incl. DATE 1=
Contractor -DateA I_ �(,� ` - VALIDATION
❑ Over 10 to 50 Incl. FINA U
am exempt under Sec. Over 50 to 100 Inc. By 0.1
B.&P.C. for this reason Over 100 it N
.. Services,Swbd.,MCC & Panelboards
.Date: 0-200 Amp.Under 600V --
Signature 201. 1000 Amp.Under 600 V
❑ - _- - _ Over 1000 Amp�or Over 600 V
Exemption for Reg.Maint.Elect.' _
SINGLE:FAMILV Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
ra•�n -
I hereby affirm that I am exempt from the Contractors License Law GT
Additional Sign,Branch Circuits 'T
for the following reason(Section 7031.5; Business and Professions, ._ .. ,. 3307- ^L.25
Does):. .7T
E] 1,as owner of the property,will do the work and the structure Misc Conduits 8.Conductors - . .-.._ 1 ITEMS .
is not intended or offered for sale (Section 7044, Business ,Other(See Complete Fee Schedule) L
'
and Professions Code). - - - 'f TOTAL • - .3 o-'ra'225
u CONSTRUCTION LENDING AGENCY' - CHECK 34.25
' -I hereby affirm that there is a construction'lending agency for the ����r� _
performance of the work forwhichthis permit is issued(Sec.3097, PERMIT FEE, (SubTotal) - • - � 4f1nI7t7G '00
Civ. C.). _
- PLAN CHECKING FEE. ODOD-0001 8730739
Lender's Name /
PERMIT ISSUING FEE 3MI- - AM10.37
Lender's Address AV
certify that I have read this application and state that the above TOTAL FEE '
information 'S correct. agree to comply with all County ordinances ..and Stat avis regulating Elect' I wiring, and hereby.authorize
rep
res fives of lh' ou y o nter upon the above-mentioned - -
prop y for inspe o rp SEE REVERSE FOR EXPLANATORY LANGUAGE _
Igna ure.of Per Date