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HomeMy Public PortalAbout5113 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.I Q'9 7 Ci 7L Company C" FOR APPLICANT,TO FILL IN SOB ❑ ADDRESS �V 'Certified copy is hereby furnished. New Residential Bldgs.&Pool- EACH NO. FEE $ _ $ LOCALITY �� C.- Certified -Certified copy is filed with the co ty building inspection 1&2-FamilY,Sq.Ft. NEAREST de artment. Multi-family Sq.Ft. CROSS ST. Date g Z Z Applicant Residential Swimming Pools a ASSESSOR MAP BOOK _ PAGE PARCEL CERTIFICATE OF EXEMPTION FROM-WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM NAME p w 6 An, First 20 MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS Z Z d s• �2 GIW I) f 4— permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITYA.L�f} Lj – Tel.No.3©t� c�dZc� 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 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 P Y P Y - APPLICANT � U.-_ ��L C'E'1'�-� C_ provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS qq `f tj J 0- I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH Ir S���– t` 0 (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. Professions Code,and m license is in full force and effect. rJCtv_Sfiti 31a j e 1 Sr C Y RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR fz c/ Power Apparatus&Large Appliances REG.NUMBER Z `1 S Class.C_ O License Number Z D S Lic.Class I a Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROC SSED BY Up to 3 Incl. LLI Z) PILL– G�liAAIa- �7 L Over 3 t0 10 Incl. FINAL ContractorDate DATE Over 10 to 50 Incl: VALIDATION Z ❑ I am exempt under Sec. Over 50 to 100 Incl. ( 100 - FINAL B.&P.C.for this reason Over 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 2 Exemption for Reg.Maint.Elect. += SINGLE FAMILY Temp.Power Pole&Appurtenances ACC 1 A HOME OWNER-BUILDER DECLARATION it h Circ n Br Sign with One acu ; ���y 1�yC �j1J' I hereby affirm that I am exempt from the Contractor's License Law Sig ,7,71J7 ° for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits i T�E MS Code): 1 1 p El1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL i65 s 69 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 16`°LL79 and Professions Code). , `NECY, 1 CONSTRUCTION LENDING AGENCY CillUltlG ° ` 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) 9 Civ.C.) 0000-0001 9/ 2/92 PLAN CHECKING FEE ;t o .. Lender's Name ��y 1 A i11`1 PERMIT ISSUING FEE y / 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 pr a ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE c��Q SI Fl1RE OF APPLICANT OR AGENT DATE