HomeMy Public PortalAbout5756 ENCINITA AVE_Building__ WORKERS'CI hme hcIO certificate
of coON 76A663 IO/BI APPLICATION
PP per` p Si ION FOR ELECTRICAL
IC.I`TRIC p A fmERMIT
hereby affirm that I have a certificate of consent.to srlf CE-BU6G {"Sr IL O'�siW Y II CI Ir 0'( IG IL G'b 0 II'l i"i IL Ir IG YHY Y
insure, or o certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certified copy thereof (Sec. 3800, Lob. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB 9` 67_4Z
�-y � `�J ,wry /
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS J ✓[s / 17l
❑ T97MPC F e '
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft.—
tion
— 5 LOCALITY /�
tion department. Multi-family Sq. ft. — NEARESTO�y M�
Residential Swimming Pools CROSS ST.
WNR R
Dale Applicant
OENOAME l.'n N�I�. �ciscj/
FIRM
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec__/_Light_Sw._ MAIL
COMPENSATION INSURANCE First 20 DRESS sa�Ywe—
(This section need not be completed If the work involved by Total No. Additional CITY `r Tel. No.`2?&-?gZ
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AAPPLICHECK
APPLICANT
permit is issued, I shall not employ any person in any manner
so as to b ome ubject to the Workers'Compensat,onows. Lighting Fixtures First 20 ADDRESS
T tat No. Additional
Date l0 Applimfix
CITY Tel. No.
NOTICE TO APPLICANT: If, afterer king this Certificate of ed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range_ Heoter_D.W.
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 o.
LICENSED CONTRACTORS DECLARATION -.IL/ LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances d
Size & Type HP, KW, KVA, or KVAR' _ O
License Number Lic. Class Up to 1 Incl. FINAL ^p V
Over 1 to 10 Incl. DATE VALIDATION
Contractor Date Over 10 to 50 Incl. O
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY LAI
d
B.&P.C. for this reason Over 100 rn
Services, Swbd., MCC & Ponelboards D ?
Date: 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 Temp. Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Additional Sign Branch Circuits :92625A
Law for the following reason (Section 7031.5, Business and '
s e s a o
Professions Code): 2
❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors' 4(Sub-Totoi)
- Q o a 297 5
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D - �.o Io;0 2 9.`]5 EQ
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 07.1
7,.1 0-84
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE -.
(Sec. 3097, Civ. C.). _
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
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 laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon _
ahe above-rrentione operty f r inspection rpos . SEE REVERSE FOR EXPLANATORY LANGUAGE
/7/LY/7C/..I-- aa-si I�
S' nature of Permittee Dote