HomeMy Public PortalAbout5233 FARAGO AVE_Electrical__ ION
WORKER'S I have
a certificate
of consent to 76A669DPW(t2-9t) APPLICATION FOR ELECTRICAL PERMIT
76A663
' I hereby 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 therieof Sec. 380L.11 a C.) `e
Policy No.\ (Sec.
FOR APPLICANT TO FILL IN JOB
ADDRESS
3� QAC
Certified1copy is hereby furnished. New ResidentialBldgs.&Pi NO. EACH FEE
LOCALITY
\ — $
El
Certified copy is filed with the county uil gin ection 1 &2-Family,Sq.Ft. $
NEARESTdepartment. Multi-family Sq. Ft. CROSS ST.
� +— Residential Swimming Pools ASSESSOR,y_Q�
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM W KERS' Cutlets:Rec. Light Sw. OWNER ORl—
COMPENSATION INSURANCE FIRM NAME � .✓k
{1
(This section need not be completed if the work involved by the First 20 MAIL Total No. Additional ADDRESS � � aM`kc- J
permit is for one hundred dollars(5100)or less.)
I certify that in the performance of the work for which this permit CITY'
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 RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS \C� S S 04L
-
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. `
(commencing with Section 7000) of Division 3 of the Business and CITY
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl,
Over 50 to 1001nc1. REGNNU BOR
ER `-�� Class.C,lI a
Over 100 DISTRICT NO. P SED BY 0
License Number ' ` ` \ Lic.Class C p
Services,Swbd.,MCC&Panelboards �•�O ��1 ir
Contracto —' �" �'"� �ate l� `t�' 0-399 Amp. Under 600 V FINAL O
DATE pp
❑ I am exempt under Sec. 400-1000 Amp. Under 600 V 1p� VALIDATION U
Over 1000 Amp.or Over 600 V W
FINAL
CLB.&P.C.for this reason BY
BRANCH CIRCUIT FEES (n
Date: 15A,or 20A, 120V,Lighting or Recept. z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) '
and Professions Code).
CONSTRUCTION LENDING AGENCY
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)
Civ. C.)
PLAN CHECKING FEE
Lender's Name 76
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE /Sire
that the above information is correct. I agree to comply with all County �J
ordinances qreg lating Electrical wiring,and hereby authorize
representatiun to enter upon the above-mentioned property
for inspecti
SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATOR MILT DATE