HomeMy Public PortalAbout5436 ENCINITA AVE_Electrical__ WORKERS' COMPENSATION DECLARATION avw319 APPLICATION FOR ELECTRICAL PERMIT O
I hereby,affirm thUt I have a certificate of consent to sell ';.76Ap
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��LL�Company FA! MO QST FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS. •�/.) 1 6
Certified copy is filed with the county'building inspec- 1 & 2-Family, Sq. Ft. 1 71 -7 $ — S LOCALITY -8 /
lion department. Multi-family Sq. Ft. — NEAREST
1 CROSS ST.
DaleApplicant .f'. fIYResidential Swimming Pools "F A'
OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec—Light sw._ 'WAIL
COMPENSATION INSURANCE ADDRESS I T 23 PR
This section need not be com leted if the•work involved b First 20 - Tel. No..
( P Y Total CITY
No. Additional N). I 1
the permit Is for one hundred dollars ($I00)or less.) PLAN 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
Total No. CITY Tel. No.
\
Date - O Applicant��rL1�-(N,S /,G� Fixed Appliances Not Over 1 HPPERMIT
NOTICE TO APPL ANT: If, after making this Certificate of ,
Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION N•
Compensation provisions of the Labor Code, you'must forth- ..Oven Dryer —W.M.— ADDRESS O
with comply with such provisions or this„permit shall be Top — FAU —W.H. —
deemed revoked. CITY elNo.
Hood — Fan —Other_ . �
LICENSED CONTRACTORS DECLARATION LICENSE OR _
Disp. — Room Air Cond. REG. NUMBER �> 2F. Class. !—O
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. OC SAD B a
and Professions Code,and my license is in full force and effect.
Size 8 Type HP, KW, KVA, or KVAR O
License Number_tos-49 Lic. Class C-f D Up to 1 Ind. FINAL I 0
Contractor L'AA rL-111A LFA Date 'f_/z� �/D Over I to 10 Incl. DATE (� \ VALIDATION 0
❑ Over 10 to 50 Incl. FINAL 0
I am exempt under Sec. Over 50 to 100 Inc. gy 0
W
B.&P.C. for this reason Over 100 Il
Date:
Services, Swbd., MCC 8 Ponelboards D r Z
. 0- 200 Amp. Under 600 V
Signature LArkI Ji 4ya 201 - 1000 Amp. Under 600 V
❑ _ Over 1000 Amp. or Over 600 V
Exemption for Reg. Mainz. Elect.
SINGLE FAMILY Temp. Power Pole &Appurtenances Y
HOME OWNER-BUILDER DECLARATION y
t'i'
'"I`"�'
hereby affirm that exempt from the Contractor's License Sign with One Branch Circuit Ot
Low for the followingg r T
reason (Section 7031.5, Business and Additional Sign Branch Circuits 3307 iU._raJ
Professions Code): 1TEM..MiscConduits & Conductors S.
❑ .I, as owner of the property, will do the work and the t' {y O5
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ TCIT i ALS ® �—s
Business and Professions Code). D CHECK 93.25
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHANGE ,_1111
the performance of the work for which this permit'Is issued PERMIT FEE (Sub-Total)
(Sec. 3097, ON, C.). `
PLAN CHECKING FEE 00013-0001 2/14/90
90
Lender's Name
PERMIT ISSUING FEE W934 1 AM $C '}'
Lender's Address rs
I certify that I have read this application and state that-the TOTAL FEE b
above 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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Permittee �n� - OOs