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HomeMy Public PortalAbout6032 GOLDEN WEST AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 20-ooteDPW 3ia7 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE 806G insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a.certified copy thereof (Sec. 3800, Lab. C.) Policy No. Q8� 22 Company C/�/� ,FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. - �� New Residential Bldgs. & Pools EACH NO. FEE ADDRESS (certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft._� JCJ _ � 4 c 0- _tion department. Multi-family Sq. Ft. NEAREST CROSS SL Lbs J C� Residential Swimming Pools OWNER OR Date / 7 Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM RKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit 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 1 ADDRESS Additional Total No. CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after makingthis Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION �' �} _ZF -SCC L Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 2 'Z tC with comply with such provisions or this permit shall be Top — FAU —W.H. — 1 deemed revoked. CITY. / Tel. No. LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— � V 2 L ls- Disp. — Room Air Cond. LICENSE Class. I hereby affirm that I am licensed . —under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. P O USED BY >_ and Professions Code and my license is in full force and effect. �f C-GL i1 ��l Size&Type HP, KW, KVA, or KVAR !/ �L�,,Ly(�G -G� Q License Numbers 7 Lic. Class U �j C� Up to 1 Incl. FINAL Q T � tractor� � Date / Over 1 to 10 Incl. DATE l�5� /Z VALIDATION 0 ❑ Over 10 to 50 Incl. FINAL • I am exempt under Sec. Over 50 to 100 Inc. gY W B .&P.C. for this,reason Over 100 0- Services, Swbd., MCC & Panelboards Z ate' Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. ewnt. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances r, I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits _ Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors structure is not intended or offered for sale Section 7044, Other (See Complete Fee Schedule)_ , -s..; 3 53' 25 Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 1„:HH the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lepo _y�� s j��''•s(�lu}- Lender's Address I certify that I have read this application and state that the TOTAL FEE above 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �0 ©s Signatur o Permittee Date