HomeMy Public PortalAbout5434 ENCINITA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION :zoaotvol+w slap APPLICATION
11 �tP` p��®OCI Ir®tl'� ELECTRICAL PERMIT
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.CE.803 Alf"Ir IL CA
I hereby affirm chat I have a certificate of consent to self ce.eoec
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. -i 1 � `C Company -f-AtRMon11 FOR APPLICANT TO FILL IN JOB j
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS s
Certified copy is filed with the county building inspe<- 1 &2-family, Sq. Ft. I T t "T $ = $ LOCALITY 1
r_1
tion department. . I Multi-family Sq. Ft. — NEAREST
te�-
Do1 Applicant /,&73 LH1.I;/�1 / 'F Residential Swimming Pools CROSS ST.
OWNER
E
FIRM
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec—Light_Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total No Additional CITY Tel. No.. 3!
the permit is for one hundred dollars ($100) or less.)
I certify that in :he performance of the work for which this PIAN CHECK
permit is issued, I shall not employ any person in any manner APPLICANT
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
I Additional
Dote 2- 1-h- q O Applicant 1"M 1r•U4 /_fh Total NCITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over I HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H.
deemed revoked. Hood — Fan —Other— CITY _ Tel. No.ao _7<j
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER L4W,-4f, Class.C'!O
(commencing with Section 7000)of Division.3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P C SED BY >_
and Professions Code, and my license is in full force and effect. 0 11( / d
Size &Type HP, KW, KVA, or KVAR (/— Q
License Number .k),/,!'4�1 Lic. Class P� 10 / U
�— Up to 1 Ind. FINAL
Contractor�bAl 4smA - Over 1 to 10 Ind. DATE w VALIDATION 0
❑ /-ff Date Over 10 to 50 Incl. FINAL O
am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 d
_ Services, Swbd., MCC& Panelboards V)
Date' 1 0- 2D0 Amp. Under 600 V D Z
Signature L F*AI IEJ rA 14;' . 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION- Temp, Power Pole & Appurtenances a
ACC•T.a
I mdSign with One Branch Circuit
hereby affirm that I am exempt from the Cora
or's License -c
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): - 1 ITEMS
❑ I, as owner of the property, will f Other Complete ete Fee Schedule)— TOTAL o the work and the Misc. Conduits &Conductors
312 s35
structure is not intended or offered for sale(Section 7044, ( P
Business and Professions Code). DC:HEi:K �R'..�0=t
CONSTRUCTION LENDING AGENCY CHANGE ..O IU
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE 0000-0001 2/1fI
Lender's Name
PERMIT ISSUING FEE "vSr.:O 1 AM E•=22.
Lender's Address r „/
I certify that I have read this application and state that the TOTAL FEE '9`
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 ro
Signature of Permittee Dc5te s �'