HomeMy Public PortalAbout5117 FARAGO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW 9/69 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.1(D9 7 Z 6.14 Company LAIA FOR APPLICANT TO FILL IN JOB l y
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Certified copy is hereby furnished. New Residential Bldgs.&Pools _ EACH NO. FEE. ADDRESS��r/
—
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ $ LOCALITY
de rtment. Multi-family S Ft. — NEAREST
G p y q CROSS ST.
Date / z- Z` Applicant QiC 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 Total No. Additional ADDRESS
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CIT 0h r� 2 Tel.NoZ(p4). Z9
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 CHECKPLAN
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 � � QQ
APPLICANT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH }
LICENSED CONTRACTORS DECLARATION • ADDRESS!S 3 Z Z �-s �U [L
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH / ''^� n
(commencing with Section 7000) of Division 3 of the Business and CITY Tel
.No:73L,641 U
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE ORCc
pp Power Apparatus&Large Appliances REG.NUMBER L-70 919Class. Q
License Number L7 D� Lic.Class G/ O Size&Type HP,KW,KVA,or KVAR DISTRICT NO. P OC SED BY
Up to 3 Incl. �ed W
ti LZ_
I Over 3 t0 10 Ind. FINAL CLContractorA 41L' F— DatesDATE
Over 10 to 50 Incl. Z
❑ I am exempt under Sec. Over 50 to 100 Inc[. FINAL VALIDATION
Over 100
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. 2
SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT e T
HOME OWNER-BUILDER DECLARATION t
I hereby affirm that I am exempt from the Contractor's License LawSign with One Branch Circuit ,�7 165.69
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 1 ITEMS
Gt TT�t 1S
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL
:146c--5 i
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ' �ft f 16 5 p
CW
GE
Professions Code). 4 .�f6
CONSTRUCTION LENDING AGENCY GE .VCi
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) Y 0 �jLI
Civ.C.) PLAN CHECKING FEE .>- � 1 9/ 2/92
Lender's Name a '�`
PERMIT ISSUING FEE Z 7 1 AM 11: .:
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE Gs. 4
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
pro rty for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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NATURE OF APPLICANT OR AGENT--
DATE