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HomeMy Public PortalAbout6036 GOLDEN WEST AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O • I76A `hereby affirm that I have a certificate of consent to self cEeo�aG insure,'or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or oacertifie copy thereof (Sec. 3800, Lab. C.) ?olicy No. OO S'—'–Company--�!57_;t E)C::-- FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. 41–yJ New Residential Bldgs. & Pools "� EACH NO. FEE ADDRESS ElCertifiedcopy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. CJ 1 $ — $�� LOCALITY tion department. Multi-family Sq. Ft. NEAREST IF t}+�`�� �� f Residential Swimming Pools CROSS ST. IJ Q Dated 1—L!Applicant OWNER OR ^ FIRM NAME CERTIFICATE OF EXEMPTION FROM W KERS' 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 ADDRESS Additional Total No. CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making .this Certificate of Fixed Appliances Not Over 1 HP PERMITQ � .•.� � -�' Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION Compensation provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall-be Top FAU —W.H. — deemed revoked. `' CITYe�. Tel. No. LICENSED CONTRACTORS DECLARATION Hood — Fan —Other_ O ` D Dis — Room Air Cond. _ LICENSE OR I hereby affirm that I am licensed under provisions of.Chapter 9 P• REG. NUMBER Class. e (commencing with Section 7000)of Division 3 of the Business Pow6,r Apparatus& Large Appliances DISTRICT NO. P SED BY >_ and Professions Code,and my license is in full force and effect. 11 e Ll Size &Type HP, KW, KVA, or KVAR �.'�� ,��Q� Q License Number "Lic. Class C �� Up to 1 Incl. FINAL V C` �2 �^—j Y.--g� Over 1 to 10 Incl. DATE �j�, �� VALIDATION aCC nt c or ��'' Date 0 Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. gy U 100 a- Services, for this reason Over d Date: Services, Swbd., MCC& Panelboards Z 0-200 Amp. Under 600 V , Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Over 1000 Amp. or Over 600 V aint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit •q^ =, Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): _yi_i{ ;_` , ❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors a ' structure is not intended or offered for sale( M Section 7044, Other (See Complete Fee Schedule)_ -- Business and Professions Code). L 1--° }',' CONSTRUCTION LENDING AGENCY L•HtiK I hereby affirm that there is a construction lending agency for F�:' .'"' the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 'r H1' (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name c !:: ,' PERMIT ISSUING FEE fiI i x( Lender's Address P )° 1 certify that I have read this application and state that the TOTAL FEE �� 0s 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 ve-mentione p y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Signature Pe ttee Date