HomeMy Public PortalAbout5107 FARAGO AVE_Electrical__ vow �1
-WORKER'S COMPENSATION DECLARATION DPW 9fB9
76A663 APPLICATION FOR ELECTRICAL PERMIT IJ
• • 76A663
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.) n
Policy No./ Z L 7 Company G IVA FOR APPLICANT TO FILL IN JOB
❑
ADDRESS S
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
$ — $ LOCALITY 7' it-
C;
Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. E�
Py y g P NEAREST
pdep m nt. Multi-family Sq.Ft. CROSS ST.
Date ` �/ 9 Z Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR d
COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM NAMELJ
First 20 MAIL
(This section need not be completed if the work involved by the
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS(7
�ZO V _5. 212J11 Qnhk'
I certify that in the performance of the work for which this permit CITY Lh Tel.No.3�dr 6Z�
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the,Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of , CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT � � gg
P P y APPLICANTS b l..t_.C/A- -C._ I�s G.
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >.
LICENSED CONTRACTORS DECLARATION ADDRESS!S 3 Z72_ �2a C�1—�/LI CL
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with Section 7000) of Division 3 of the Business and CITY 7'�7�'�J Tel.No.j3 L-a y 7
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
Q� Power Apparatus&Large Appliances REG.NUMBER Z-7tf��S Class.G( a 0
License Number v Lic.Class C4 O Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PR C SED BY
Up to 3 Incl. Q �G a-
D\ � � 4� G� Z C Over 3 to 10 Incl. FINAL co
Contractorf) �CJLLDate 7 Over 10 to 50 Incl. DATE / Z
El am exempt under Sec. Over 50 to 100 Incl. Io�/ -q3
`Q 3 VALIDATION
Over 100 - FINAL
B.&P.C.for this reason - BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V '}
Signature 201 -1000 Amp.Under 600 V a /�
❑ Over 1000 Amp.or Over 600 V ACCUT,
Exemption for Reg.Maint.Elect.
3307 165.69
SINGLE FAMILY Temp.Power Pole&Appurtenances ITEMS
7 ptc
HOME OWNER-BUILDER DECLARATION 1 ITEMS
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits TOTAL 16I.c: . 69
Code): t j;
^r
El 1, 165.6
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , CHAME .00
and Professions Code). ---
CONSTRUCTION LENDING AGENCY ��{��y(1 f�f 6
I hereby affirm that there is a construction lending agency for the 0000-0001 7gl/.t 2/9''
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Q 5322 1 AM11:11
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE Z
Lender's Address p
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
rep sen
Iatives of this County to enter upon the above-mentioned
Ipr r_ty for inspection�pZur, oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
cc�L�Q 9 L
SI ATIiRE OF APPLICANT OR AGENT DATE