HomeMy Public PortalAbout5114 DOREEN AVE_Electrical__ WORKERSCOMPENSATION DECLARATION 76-663 ,D,B, APPLICATION FOR ELECTRICAL PERMIT {�
F hereby
CE-806G �f
. y'affirm thxat I havg a certili ate of consent to self insure,•
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800.Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB r /
EACH NO. FEE ADDRESS , /�4 TDOeaeN ver
Certified copy is hereby furnished. New Residential Bltlgs.8 Poo�.(�/�
❑ 1 & 2-Family,Sq.FL �–* r `" $ — $ LOCALITY �M LC G/T
Certified copy is filed with the county building inspection
department. Multi-family Sq.FL — CRCBS SST
Date Applicant Residential Swimming Pools OWNER OR Z
(} �,0 FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' /�-�L .L/_V MAIL
Outlets:Rec Light Sw. 9'
COMPENSATION INSURANCE ADDRESS p S•�r/ti /"1
completed if the work involved b the First 20
20
(This section need not be com
p y Total No. Additional ICITY HECK A�K Tel.No
permit is for one hundred dollars($700)or less.)
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT .jA/ht it
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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 ADDRESS
(p� / Additional
Date `� '� U Appli �6�91/V�*� Total No. /0 - CITY Tel.No.
PERMIT
NOTICE TO APPLICANT: It, after making this Certificate of Fixed Appliances Not Over t HP APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT
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provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer W.M. T ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU W.H. L
LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_ CITY Tel.No.
1 hereby affirm that I am licensed under provisions of Chapter 9 Dis — Room Air COM. ov LICENSE OR Class.
(commencing with Section 7000) of Division 3 of the Business and D REG.NUMBER
Professions Code,and my license is in full force and effect. -Power Apparatus& Large Appliances DISTRICT-NO. PROCE BV
Size& Type HP,KW,KVA,or KVAR a o
License Number Lic.Class Up to 1 Incl. FINAL/ U
Over i to 10 Incl. DATE L/Vl
Contractor DateVALIDATION U
Over 10 to 50 Incl. -
El
am exempt under Sec. Over 50 [0 100 Inc. FINAL
By W
0_
B.&P.C.for this reason Over 100 N
Services,Swbd.,MCC& Panelboards D Z
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
r_1 Exemption
1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law ACCT.:
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits -
Code): 3307 'S.10
I,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)
and Professions Code). D TOTAL 83 - 20
CONSTRUCTION LENDING AGENCY CHECK 23.2113
I hereby affirm that there is a construction lending agency for the CHANGE .W
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (SubTotal)
Civ.C.). ••
Lender's Name PLAN CHECKING FEE 113000-01301 S/ 3/90
PERMIT ISSUING FEE
Lender's Address . � ^ 2208 1 AM 9:-14
1 certify that I have read this application and state that the above TOTAL FEE .OS
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 mapped urposes. 3 Q SEE REVERSE FOR EXPLANATORY LANGUAGE '
9 nature of Iladimalee Date —�J