HomeMy Public PortalAbout9917 GARIBALDI AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 7BA663
CE,-8,06G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby afftrm that I have a caMficate of consent to golf COUNTY OF LOS ANGELES BUILDING AND SAFETY.
Insure, or a certificate of Workers'Compensation Insurance,or
■certified copy thereof'(Sec.380-0,Lab.C.) �� Q� T
FOR APPLICANT TO FILL IN JOB
Policy No.—Company /
New 13esldentlel Bldgs.&Pools EACH NO. FEE gDDRE83 .
❑ Certified copy Is hereby furnished. 1 &2,Famlly,Sq. Ft. — $ ' LOCALITY
Multl-femlly Sq. Ft.
Certified copy is filed with the county building lnspection CROSS ST
department, Realdentlel Swimrrlina.f'ools
OWNER OR'
DateFIRM NAiNE
Applicant Qutletr. Rec�Light Sw. MAIL
--7Irst 20 ADDRESS 4,V
CERTIFICATE OF EXEM15"I'ION FROty(WORKER' Tot&I Nb.. Additional
COMPENSATION INSURANCE CI-TY Gm � !>N .
PLAN CHECK
(This section need ndt be ieted.if the work tmul�ed APPLICANT
by the- permit is for one hundred donut (_�00) or jogs) Ughting Fixtures First 20 Additional ARPRESS
Total'No.
I certify that Ln the. performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. Q
P--ft b Issued, I than not employ any person In any manner PF RMI 8
w as to become subject to the Work Compbnzatlon Laws. Range_Heater D.W. PP CANT LLI
�J �� _ LOveh _ Dryer._W.M.T_ ADDRESS'
Detdl- 1 d' .Applicant op _ FAU. _W.H.T
Fen _Other ,
CITY Tel No.
NOTICE TO APPLICANT: If,.atter making this Certificate of Isp, ., Rooni Air Cond— LIQEN8E OR
ExQmptlon, you should become subject to the Workers' REG.NUMBER Claw
Compensation provisions of the Labdf Code, you must forth- ?ower Apparatus Large Appliances DISTRICT NO, ' PROCESSD BY
with dcomoly
revoked.with such provisions or this permit Shan be
teamed revoked. Slza&T'ypb HP,KEN,KVA,or KVA I p t`
IJP to 1 Incl. v
FINAL
Over 1 to 10 Incl. DATE VAL�DATJON .
LICENSEIS CONTRACTORS bECI ARATION ��-' --
a � Over 10 to 60•Incl. ,
I hereby affirm that I am licensed underFINAL
prbvisjons pf Chapter Over 60 to 100 Inc. BY a .
9 (0mmegc1149 wtt� Section 7000}of bivhlon 3 of the Bust- Over 100 `
nass and'Professiogs,Code, and my license Is in full force and
bffect. Services .� _
0-200 Am P. U der$ V !r
' License Number 21:91i XLic.Claes
39 _ C �D
��--++ e 201-1000 Amp. Under 600 V 6
�p
Contnctbrr'L4eh/wZrL�Data Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER bECLARATION Terpp.Power Pole&Alp purteneneas
I herebyaffirm. that I am exempt Stan with'One Branch Circuit
tXom the 031-5, Bt 2 Additional $Ign Branch Circuits.-.
License 1,a�' for the following reason (Section 7031_S, Bust- •
nese and Professions Code):
Misc.Conduits&Conductors2 O'El 8-A
I, es owner of the proporty, wild do the work and the Other (See Complete Fee Schedule►—
structure is net Intended or offered for sale (Section # oro 0 0 0 2
7044, Business and Professions Codd).
CONSTRUCTION LENDING AGENCY '2;- o 1 9. 50
I hbreby•tfftrrn that there is a centtruction lendipg agency
for the perfotmance of the-work for which this permit is PERMIT FEE (Sub-Total) .o 0 0 1 9.5 O 6
issued (Sec. 3097,Clv.C.)_
Lender's Name PLAN CHECKING FEE (On�Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
'I certify that I have read thjs'applicatiori and state that the TOTA1,FEE
above information Is correct.I aipreb to comply with 0 County
ordinances and State saws regulating Electrical wiring, and.
hereby authorise ropraentatlyes of this County to enter upon
the ab mentioned pro for Ins action purpotw. SEE-REVERSE-FOR EXPLANATORY LANGUAGE - r
Signature of Permlttee . Data J J.