HomeMy Public PortalAbout5111 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.) j
Policy No._[69.7 Z 10 G
-2�e Company •v,4 FOR APPLICANT TO FILL IN JOB
ADDRESS -AA 0
❑ Certified copy is hereby furnished. New 1&2-Family,Sq.Ft. $ o Bldgs.&Pqqo EACH NO. FEE
! — $ LOCALITY
Certified copy is filed with the count building inspection — �,e Nl 1 C� -� `7
dep meet. Multi-family Sq.Ft. NEAREST
c� CROSS ST.
Date ` Z— F ZJ Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR
COMPENSATION INSURANCE First 20 FIRM NAME MAIL 6 �, d L-)
'^
(This section need not be completed if the work involved by the Total No. Additional ADDRESS'•Z6 a S, /Z.�r,,d A/
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY Lt,A.-r,6 A_A— Tel.No. �,66^60s
is issued, I shall not employ any person in any manner so as to PLAN
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
K
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 �\ t �Y /lJ Lei 1
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH APPLICANT ,Q ` .
LICENSED CONTRACTORS DECLARATION ADDRESS rj ?��Z / 2d cil` j/j
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 NJC/ tf l`/Z Tel.No.�3L_<jt7 0
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
J Power Apparatus&Large Appliances REG.NUMBER Z (� �%g� class.�(p cc
License Number 9�� Lic.Class C( a Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROSED BY
Up to 3 Incl G� LU
LU
Over 3 to 10 Incl. FINAL
Contractorb6 ut/' vl—'--"Date ` Over 10 to 50 Incl. DATEh { U)
❑ I am exempt under Sec. Over 50 to 100 Incl. /U— —q 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
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect. y, /+
SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT.
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law g �vrtVV7 16 .59
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits.
Cade): 1 ITEMS
❑ 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL165-69
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ' CHECK 165.69
CONSTRUCTION LENDING AGENCY _ _ CHANGE .00
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE - (Sub-Total)
Civ. C.)
PLAN_ CHECKING FEE � �1 p9.p/t 2/92'
Lender's Name 53'x¢ 1 AN11:11
PERMIT ISSUING FEE � r{ 75 `
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE f t s (.9
information is correct. I agree to comply with all County ordinances 1
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
pr�fori n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
9ZGOR AGENT DAT