HomeMy Public PortalAbout5222 DOREEN AVE_Electrical__ WORKERS'CI- 1PENSATIONDECIARATION 10-0019 DP .3r91• APPLICATION FOR ELECTRICAL PERMIT O
I hereby•off irm Prot I t4%e a Eertificate m consent to self cE=-soec
,insure, or a certificate d Workers' Comperisolion Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.) •���
Policy No. .Company !! a' P FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS
ACertified copy is filed with the cou buildi inspec- I & 2-Family, Sq. Ft. •36 $ — $ 6 LOCALITY �l
on par mens. Multi-family Sq. Ft. — NEAREST
CROSS ST.
Residential Swimming Pools
WNER UK
Date Applicant X�/ FFIIRM NAME
CER IFICATE OF EXEMPTIO FROM WO ERS' Outlets: Rec_Light_Sw._ MAIL O
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITU 0M Tel. Nia _
the permit is for one hundred dollars ($100)or less.)
PLAN CHECK
certify that in the performance of the work for which this APPLICANT
permit 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
Additional
Date Applicant Total No. CITY Tel: No.
Fixed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION
Compensation provisions of the Labor Code, you most forth- Oven — Dryer —W.M._ ADDRESS EFALPTA
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CITY NA14elln Tel. No
LICENSED CONTRACTORS DECLARATION UCENS OR
Disp. — Room Air Cond.
hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER �' Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PRO ED BY ?
and Professions Code,and my license is in full force and effect. O d
Size &Type HP, KW, KVA, or KVAR U r 0
License Number Lic. Class�— Up to 1 Incl. FINAL U
_—F;rf-f S DT• t) Over I to IO Incl. DATE VALIDATION �O
Contractor — l ate O 10 to 50 Incl.
❑ Over FINAL
I am exempt under Sec. Over 50 l0 100 Inc. BY U
Over 100 W
B.&P.C. for this re d
DatServices, Swbd., MCC& Ponelboards , U)e: 0-200 Amp. Under 600 V .
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances
I hereby affirm that I am exempt from the Contractor's license Sign with One Branch Circuit Al(:T r
Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): 3307
❑ 1, as owner of the property, will do the work and the Misc. Conduits &Conductors 1 ITEMS
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ TOTALr-.
Business and Professions Code). , 1'— ® ti�
CONSTRUCTION LENDING AGENCY �'HE�•K 159,20
I hereby affirm that there is a construction lending agency for CHANGE ,OFf
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
Lender's Name PLAN CHECKING FEE
0000-0001 1/ 5/90
PERMIT ISSUING FEE 8077 Lender's Address 1 AM10e4
I certify that I have read this application and state that the TOTAL FEE 5 z�
above infor at ion is coalmply with all County
Ord'non andSlatectrical wiring, and
hereb Forize r raterupon
the -menti e tion urp ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
5 s
Signature of P mittee to os