HomeMy Public PortalAbout5115 FARAGO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW 9/69 APPLICATION FOR ELECTRICAL PERMIT
76A663 'd
I'her2by 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.) /^x'
Policy NO.! (�Zb? Company Cr_J - FOR APPLICANT TO FILL-IN JOB
ADDRESS
Certified copy is hereby'furnished. New Residential
c u ty building insp CtlOn 1 &2-Family,Sq. . $ B $ /Bldgs.&P ool EACH NO. FEE LOCALITY y^GC'-
f
Ft __� = w'
Certified copy is filed with the NEAREST
M �
de art ent. Multi-family Sq.Ft. CROSS ST.
Date 9 — Applican C�(J Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR
COMPENSATION INSURANCE FIRM NAME
First 20 MAIL
(This section need not be completed if the work involved by the ADDRESS
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY Tel.No.0&9 ?9
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
APPLICANT l
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH p }
LICENSED CONTRACTORS DECLARATION ADDRESS/_S 3 ZZ 14 �C���,
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH 0
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.;—) �,—�r( U
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
`1� Power Apparatus&Large Appliances REG.NUMBER Z 7Q 9g Class.G o
V
License Number Z,-7 9,S <— Lic.Class CA Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY 0
Up to 3 Incl. ' �Qp W
,�i�iL
Contractor Over 3 to 10 Incl. FINAL
Date n-
"r g 9 v
❑ Over 10 to 50 Incl. DATE
I am exempt under Sec. Over 50 to 100 Incl. ( ( I VALIDATION
Over 100 - FINAL
B.&P.C.for this reason BY o
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. 2
SINGLE FAMILY Temp.Power Pole&AppurtenancesAl•�I.T
HOME OWNER-BUILDER DECLARATION it h Ci
B
with O
Sign wOne Branch Circuit [ L
I hereby affirm that I am exempt from the Contractor's License Law Sig3307 165.69
for the following reason (Section 7031.5, Business and Professions -Additional Sign.Branch Circuits
Code): 1 ITM
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 16-5-469
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) L [_�
and Professions Code). , OEM 165.65
CONSTRUCTION LENDING AGENCY .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) q
D � .
Civ.C.) PLAN CHECKING FEE DOM-0mi.
iJ�
Lender's Name �1� +
PERMIT ISSUING FEE _F 1 �11�12
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
for inspectilon�urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Certy
VLTURE OF APPLICANT OR AGENT
DATE