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HomeMy Public PortalAbout4941 DOREEN AVE_Electrical__ 'WORKER'S COMPENSATION a certificate DECLARATION 76A663 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm.that I have a certificate of consent to self insure, 76A663 or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS _ BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) Policy Nog f( .r•P`9 0 57 2 Z Compatly— "7/ y� �/ FOR APPLICANT TO FILL IN AGB c, ❑ _ ADDRESS y� J•� - f/'� Certified copy is hereby furnished. New Residential Bldgs.&P EACH NO. FEE / -3 $ — $ LOCALITY C d Certified copy is filed with the county building inspection 1 ul i--Family,Sq.FL C _ �/department�:T Multi-family Sq.Ft. _ CRoES ST. 2 Date O _ L Applicant Residential Swimming Pools 'ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF'EXEMPTION FROM ORKERS' OWNER OR _J^ - COMPENSATION INSURANCE. Outlets:Rec. LightSw. _ FIRM NAME ' tsj First 20 MAIL - (This section need not be compthe work involved by the 'Total No. Additional ADDRESS - - permit is for one hundred dollarss($1($100)or less.) I certify that in the performance of the work for which this permit - - CITY - Tel.No, is issued, I shall not employ any person in any manner so as to- become subject to.the Workers' Compensation Laws'. Lighting Fixtures First 20 A PPI-AN Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making'this Certificate of CITY Tel No. Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with,such 11 TO 40INCLUSIVE EACH- APPLICANT L provisions.or this permit shall.be deemed revoked, 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION - - - ADDRESS Y I hereby affirm that I am Iicensea uri'der provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH 3 �-3 e `� d. (commencing with Section 7000) of Division'3 of the Business and _ r CITY Y(1-40 LS T.L.No. o 3 Scl J Professions Cade, and my license is in full farce and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR [ . V 'T[ (, Power Apparatus&Large Appliances _ - REG.NUMBER �� 7 L/ Class' Y Q j / 7 L/ ! �'��.J Size&Type Hp,KW,KVA,or KVAR OISTRICT.NO. PRoc SED By �jpense Number Lia Class 7/�,$/��� W / Up to 3 Incl. �� Lel -s`.^— W Over 3 to 10 Incl FINAL a Contr or Date Over 10 to SO Incl. DATE- r1y �! - Z ❑ I am exempt under Sec. 'Over 50 to 100 Incl. �'N - VALIDATION - - Over 100. - FINAL B:&P.C,for this reason BY Services,Swbd.,MCC&.Panelboards - .. Date_ 0-200 Amp.Under 600.V Signature -201 -1000 Amp,Under 600 V- -- ❑ - - - Over 1000 Amp.or Over 600 V .1 Exemption for Reg.Maint. Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION - 't�" Sign with One Branch Circuit - 1 hereby affirm that on exempt from the Contractor's License Law obi if =1_;f - for the following reason (Section 7031.5, Business and Professions AdditionaLSign Branch Circuits - obi if ..."r``T- Code): . ❑ 1,as owner of the property, will do the work and the structure 'Misc.Conduits•&Conductors - e' ITEMS +-} is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I` °�= "` — r and Professions Code). - - - - - - © - v yv. _ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the , performance of the work for which this permit is issued(Sec. 3097. PERMIT FEE .- (Sub-Total) - 3 y 7 _ Civ. C.) PLAN CHECKING FEE _ _ ,. - 1.}I'I+lj—F it l A a _'%"fr -: Lender's Name PERMIT ISSUING FEE _ a41 n1t Lender's Address " I certify that I have read this application and state that the above TOTAL FEE a� 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 above-mentioned - property for inspection urpG es. SEE REVERSE FOR EXPLANATORY LANGUAGE Lj— Zai -32 SIGNATURE OF PLICAfj Ofl AGENT DATE