HomeMy Public PortalAbout5121 FARAGO AVE_Electrical__ WORKER'S I S COMPENSATION DECLARATION 76A669 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby aflirm 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.)
Policy No. 10 9 7�L7 Company G►�/Y FOR APPLICANT TO FILL IN JOB ���
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools Tr/ EACH . NO. FEE LOCALITY
1 &2-Family,Sq.Ft. �J 6(s7 $ _ $ Ta-
Certified copy is filed with the county building inspe tion NEAREST
de artment. ` Multi-family Sq.Ft. CROSS ST.
Date Z- Applicant 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 If
(This section need not be completed if the work involved by the Total No. Additional ADDRESS / Q gyJC
permit is for one hundred dollars($100)�or less.)
I certify that in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as to �r rt Onl C( (�/�� �vq Z47
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN
APPLICANTK
Total No. Additional ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACHPERMIT APPLICANT r�O ��.� I��-e-C4 A-C—
provisions or this permit shall be deemed revoked.- 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION 15 OR 20A,208V TO 277V LIGHTING EACH ADDRESS s 3 Z
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business and CITY *T:71,,PCJ J,4 Tel.No.3 _Q�( I$ U
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR �nn�+ Cr
Power Apparatus&Large Appliances REG.NUMBER 2-7 V / Class.G V O
License Number G �/ D 5- Lic.Class C(fl Size&Type HP,KW,KVA,or KVAR DISTRICT NO. P OC ED BY I—
c� Up to 3 Incl. - J7,i U W
Contractor /J d `/�] (f L-r -(LC-Date / L Over 3 to 10 Incl. oIANTE Cr
'I�)
Over 10 to 50 Incl. %% Z
El am exempt under Sec. Over 50 to 100 Incl. V AVALIDATION
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. 2
SINGLE FAMILY Temp.Power Pole&AppurtenancesA/�/�//�� 1
HOME OWNER-BUILDER DECLARATION - ACCT
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 165.69
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ? P
Code): - -
1 ITEM
❑ 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 1 -r—° 6
7
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) � _ t
and Professions Code). , Ct�'C 165.69
CONSTRUCTION LENDING AGENCY WRQ nOL�
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) a c/
Civ.C.) t �tt��
PLAN CHECKING FEE OOOO—W01 9/ 2M
Lender's Name . 4
PERMIT ISSUING FEE Q` "ls 5M111 1v
Lender's Address / p
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
repres ntatives of this County to enter upon the above-mentioned
pro y for inspection p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
9 L s z__-
RE OF APPLICANT OR AGENT D4TE