HomeMy Public PortalAbout5430 ENCINITA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION :aomtGDPW alar APPLICATION FOR ELECTRICAL PERMIT O
I hereby,offirm that I hove c certificate of consent to self ct-em
insure, or o certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.) ,(
Policy No.Q-H U ZIT Company 77AIQMeA)7_ FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
Certified copy is filed with the county building inspec- I'8 2-Family, Sq. Ft. 1"r I '7 $ — $ OCALITY E /.- GIT
tion department. Multi-family Sq. Ft. — NEAREST
;i
Residential Swimmin Pools CRDSS ST. _
Date -5- I?-> WD Applicant L&Q F4 WA I_ g � OWNER OR
- u FIRM NAME Zili
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec—LightSw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY 'A Tel.
the permit is for one hundred dollars ($100)or less.) PIAN CHECK
I 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�-1 Total No. CITY Tel. No.
Applicant I- WA I-8F. Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLI ANT: If, after making this Certificate of APPLICATION C
Exemption, you should become subject to the Workers' Range— Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESSD
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood — Fan —Other_ CITY el. No. -74,7
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of�Chapter 9 Disp. _ Room Air Cond. — REG. NUMBER 31.14' Class. 67D
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. P O E ED Y >_and Professions Code,and my license is in full force and effect. ® d
Size 8 Type HP, KW, KVA, or KVAR _ Q
License Number 311.1"44 Lic. Class /,-ID U
� Up to 1 Incl. FINAL I
Contractor 1,20.) i-f WiN LSE Date J- /;- 9 D Over 1 to l0 Incl. DATE �t fl� /ALIDATION 0
OOver 10 to 50 Ind. FINAL VVV f-
I am exempt under Sec. Over 50 to 100 Inc. gy U
W
B.BP.C. for this reason Over 100 r d
D ,✓
Services, Swbd., MCC 8 Panelboards Z
Dote: 0- 200 Amp. Under 600 V
Signature /wrsl 1-111➢ 1_>bf_ 201 - 1000 Amp. Under 60D V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Mainz. Elect. -
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances y
s.
I hereby affirm that I am exempt from the ContractorSign with One Branch Circuit AULT
's License r
Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 33(]7
Professions Code): _ - 1 ITEMS
Misc. Conduits 8 Conductors _
s as owner of theproperty, will f o the work and the s=
Other See Complete Fee Schedule)— TOTAL 4'c�.F a V--r
structure is not intended or offered for sale 7044, ( P )
Business and Professions Code). v
CHECK
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for CHANGE ,Ijll
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). ,
PLAN CHECKING FEE 0000-0001 2/14f9C1
Lender's Name
PERMIT ISSUING FEE 3 �'4J5 1 AM &:1'f
Lender's Address '
I certify that I have read this application and state that the TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State lows regulating Electrical wiring, and _
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
(Jf'
C4rw a4a a
Signature of Permittee — ,.