HomeMy Public PortalAbout5109 FARAGO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm that I have a certificate of consent to self insure, 76A663
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.) ('
Policy No. 109 7 Z67>o Company v F FOR APPLICANT TO FILL IN JOB ®�
ADDRESS /
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
LOCALITY C
Certified copy is filed with the count building inspect' n 1 &2-Family,Sq.Ft. lr5e $ — $
NEAREST
de rtment q ' / Multi-family Sq.Ft. CROSS ST.
Date Applicant
t.��6/+/!/w Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER ORa 'O
COMPENSATION INSURANCE FIRM NAME t-y
First 20 y
(This section need not be completed if the work involved by the MAIL
Total No. Additional ADDRESS Z� S, F'2R-NMbAf-f-
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY gL-11 A 01 S A4 Tel.NoJd,6_,6& J
is issued, I shall not employ any person in any manner so as to PIAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V 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 y
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH APPLICANT
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH d
(commencing with Section 7000) of Division 3 of the Business and CITYV�Q(vS r� Tel.No33(�—d`I'8 O
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR O
Power Apparatus&Large Appliances REG.NUMBER L 7 d y 5 Class. C I(�
License Number d 9 Lic.Class G I O. Size&Type HP,KW,KVA,Or KVAR DISTRICT NO. PROCESSED BY O�
q Up to 3 Incl. DO lS�y�•�/� W
Contractor A Lit Date ` 9 L Over 3 to 10 Incl FINAL Cn
DATE
❑ Over 10 to 50 Incl. .�
I am exempt under Sec. Over 50 to 100 Incl �> VALIDATION Z
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V 7
Signature 201 -1000 Amp.•Under 600 V ACCT-V
F7Over 1000 Amp.or Over 600 V �7 165.69
Exemption for Reg.Maint.Elect. 3307
SINGLE FAMILY Temp.Power Pole&Appurtenances 1 ITEM
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ToTAf 16"6;o 69
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits LR i L .
Code): 10
69
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors CH"E .011
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ► �,�j
and Professions Code).
CONSTRUCTION LENDING AGENCY UU1J1 7, 2/9
1 hereby affirm that there is a construction lending agency for the 1 (rttlll�11
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Vo .-q 5323
Civ. C.)
PLAN CHECKING FEE Z1`f 75
Lender's Name
PERMIT ISSUING FEE
Lender's Address
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
representatives of this County to enter upon the above-mentioned
ZprXf , specti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE