HomeMy Public PortalAbout5119 FARAGO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT u
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. v17 L G" Company CKV,0 - FOR APPLICANT TO FILL IN JOB �/� a �
❑ ADDRESS 'Y/
Certified copy is hereby furnished. New Residential Bldgs.&Poole / $EACH NO. $ FEE
�j (G LOCALITY 7'��
Certified co is filed with the unt building Ins tion 1&2-Family,Sq.Ft.
I PY Y 9 P NEAREST
depa meN Multi-family Sq.Ft. CROSS ST.
Date c��V Residential Swimming Pools ASSESSOR
9 Applic �, Q•-• MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets;Rec._Light Sw. OOWNER OR FIRM NAME 1 6,4 _1 L~/
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MA�RESS( 1j G l r .} �j I!/k .4 C h
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 0,•/*M 6 jC( -4 Ill Tel.No. 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 r 1�_ /t ' +
P Y P Y -� APPLICANT ALA,
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provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS I S >_3 ZZ 2E c,-� c� t_
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH CITY O
Tel.No. V
(commencing with Section 7000) of Division 3 of the Business and �� (J yti
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR �+
7 c� Power Apparatus&Large Appliances REG.NUMBER �� V / Class.
License Number Z� I Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. �/ PR C ED BY
Up to 3 Incl. a W
\ /^ /�/ J Over 3 to 10 Incl. FINAL n-
Contractor jam' ��—Y4 �`fjate Z Over 10 to 50 Incl. DATE �Q U)
❑ I am exempt under Sec. Over 50 to 100 Incl. 1,61
—t VALIDATION
FINAL
B.&P.C.for this reason Over 100 BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201 -1000 Amp.Under 600 V
El
Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances y
HOME OWNER-BUILDER DECLARATION r; !1 �1�JL
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit AC
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for the following reason (Section 7031.5, Business and Professions Additional Sign_Branch Circuits _ 3307 145.69
Code):
❑ 1
MiITEMS
I, as owner of the property, will do the work and the structure sc.-Conduits&Conductors _ �t ..
T
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , TOTAL 1465-69
and Professions 04ECK
i t�.t
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CONSTRUCTION LENDING AGENCY E iGl— _ ���
I hereby affirm that there is a construction lending agency for the CHAWG
performance of the work for which this permit is issued Sec. 3097, �J
P P ( PERMIT FEE (Sub-Total) !-7 d _9
Civ. C.)
PLAN CHECKING FEE OM --M1. 9/ 2/9.4
Lender's Name 17
PERMIT ISSUING FEE 4— 5 532 1 AM11:13
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
re resentatives of this County to enter upon the above-mentioned
perty for inspec on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
L
URE OF APPLICANT OR AGEl DAT