HomeMy Public PortalAbout4931 HELEO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-866 . to/at APPUl�9AMON FOR Ep EC MICA PERM
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+I hereby affirm that I have a certificate of consent to self insure,
CE-8066 UV LLS II l� L� LS IfUIIIlII
or a certificate of Workers' Compensation.Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec. 3800,Lab.C.)
Policy No. Company - FOR APPLICANT TO FILLAN ' JOB % 4 ve y
EACH NO. FEE ADDRESS
F-1. EA
. Certified copy is hereby furnished. .. .,' New Residential Bldgs.& Pools ,
_ S LOCALITY 7
❑ $ Jap .
Certified copy is filed with the county building inspection 1;&.2-Family,Sq.Ft. �/
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR /
FIRM NAME L ,01/ rad
CERTIFICATE OF.EXEMPTION FROM WORKERSOutlets:Rec 6O- Light Sw. MAIL
COMPENSATION INSURANCE ADORES$�y2
This`section need not be completed if the work involved b the � � First 20
( P Y � CITY'-r Tel.No.
permit is for one hundred dollars,($100)of less.) Total No:"�J Additional /+ ���'f 7qo
I certifythat,in the performance of•the work for which this permit PLAN CHECK
A P � APPLICANT
is issued, I'shall not employ any person in-any manner so as to
become subject to,the Workers'.Co_mpens tion Laws.' Lighting Fixtures, First 20, ADDRESS
Additional
Total No. CITY - Tel.No.
'Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making ,this •.Certificate of PERMIT
Exemption,you should become subject.to.the Workers'Compensation Range 'Heater_ D.W. APPLICANT / 1 ,e/
provisions.of the Labor.Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS
provisions or this,permit shall be deemed revoked. Top FAU W.H. _
LICENSED CONTRACTORS DECLARATION. Hood Fan _ Other_ 1.7CITY
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. �_ Room Air Cond. LICENSE OR
(commencing with Section 7000) of Division 3 of,the Business and REG.NUMBER ]/y ClassG_/v
Professions'Code,and my license is in full force and effect. DISTRICT NO PROCESSED BY
p/ Power Apparatus& Large,Appliances a.
y7 Size& Type HP,KW,KVA,or KVAR O U
License Number l D 80 Lia Class [ y Up'to 1 Incl. FINAL
ContractoAP/tiLdS 8-16C- Date 7-1?-B9 Over 1 to 10 Incl. DATE VALIDATION, 0
O:
Over 10 to 50 Incl. FINAL ( U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W'
Over 100 Q.
B.&P.C.for this.reason + I✓7
Services,Swbd.,MCC&•Panelboards D @
Date: 0-200 Amp.Under 600 V /
Signature 201 - 1000 Amp.Under 600 V
Elo Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY -Temp.Power Pole & Appurtenances t 2
HOME'OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm,that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits e
Code): 3M7 93.00
Misc.Conduits&Conductors p�_•�v
❑ I,as owner of the property,will do the,work and the structure,
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and YtyY Professions Code). D tvt� 93 o IDI®
CONSTRUCTION LENDING AGENCY . CHECK 93gLEiJ
Thereby 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) gO? " "':`' bYliur '.• " oLW
Civ. C.).
PLAN CHECKING FEE
'Lender's Name 7/19/89 r
PERMIT ISSUING FEE dd q�td
Lender's'Address 4 d AH103-o40
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
represe tatives of this'Co my to enter upon the above-mentioned
property f inspeZee
u poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
7 -/q•- 8c/
Signature of PermDate