HomeMy Public PortalAbout6128 IVAR AVE_Electrical__ WORKERS'COMPENSATION DE [��r p �a 2
• h +-•r k DECLARATION .:� 76Ass3 1'0/81 22p� �9 g�p l�2 ��,nn
}• ereby#3fi1rm that,I h26e a certificate of CE-Bose
,`•APP L ICAMON' FOR E L E�vTMICAL�. I�L�Ru@7 T
' consent to self insure, ,a ,-
.6rr a certificate'of Workers'.Compensation Insurance, or a'certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy'thereof(Sec.3800,Lab. G.)
Policy NO"- Company - _ FOR APPLICANT TO FILL IN^ JOB
Certified copy is hereby furnished. New"Residential Bldgs;& Pools;, EACH NO. FEE
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1' Certified•copy.is filed,with the;county building inspection `1 & 2-Family,Sq.Ft.
� j'•�FATE
;. Multi family Sg,Ft. — COO BSSY
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g•PoolsPP minResident'al SwimDaeEX` }
OWNER'OR'''�
• } FIRM NAME
EMPTION FROM'WORKERS !/ !t
Outlets:Rec: Light —Sw.
4; COMPENSATION INSURANCE ,"ADDR_ESS `
First 20
This section need not be com letedif the workAnvolved by the 7 A�
( p s -^CIlYJ A� ��q{�r� Tel.No. .,
..Per one one hundred dollars($:100)or`less.) ,
Total'No. Additional AVI,►RoLI
•i •' ��� PLAN CHECK"
''I certify that in the performance of-the•;work':for whicli`this permit APPLICANT
is issuedo l,ahall,not,,employ. any,person,in any:,manner'so as to
become,.su ject to,4he Workers'Com ensation Laws ; Lighten :Fixtures First P 9:, first 20,: (oma ADDRESS
Additional
Qk4lTotal No: Ad. CITY, Tel No
Date Applicant >�_.�
NOTICE TO:'. P.PLIC NT,,.If)• after. along _thls;,Certificate.,of Ffzed,Appliances Not Over 1 HP PERMIT
p�
Exemption,you should become subject to the Workers'Compensation, Range_ •Heater_ D.W.,
APPLICANT
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provisions.of thezLabor Code; you'must forthwith comply With such `,Oven Dryer_ _W,M._ ADDRESS
.;provisions or this permit tiall,be deemed revoked. Top FAU W:H. CITY - Tel.No.
LICENSE6'CQNT,RACTORS DECLARATION Hood Fan —"Other
Ithat
_
.hereby.affirm that•I am licensed under'provisions of:Chapter 9 LICENSE OR
Disp. Room'Air Cond. Class
(commencing with Section 7000) of:Division,3 of the..Business.and REG.NUMBS
ProfessionsCode,and my'license is in, ull force and effect.: _ DISTRICT NO P OC SED BY
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,Power,Apparatus&•Large'Appliances .�
Size & Type HP KW,KVA,or KVAR � �
License Number Lic Class Up to 1 Incl. ''� FINAL'
Y
Over 1 to 10lncl ✓Z O
VALIDATION
•DATE '
Contractor Date •`
Over 10 to 50 Incl
❑ .I am exempt under,Sec. :; Over 50 to :100 Inc By FINAL li d 't
BA r P C.for this reason " Over 100
Seryices,Swbd MCC & Paheiboards t _
Date:
0-200 Amp.Under 600•V
Z
Signature 201 --1000 Amp..;Under-600 V
Over 1 000Amp.or Over 600 V
Exemption:for Reg.Maint.Elect:
SINGLE _Temp.-.Power Pole&Appurtenances
r HOMOWNER-BUILDER,ERI
EDECLARATION Sign wdh'One Branch Circuit
I hereby affirm that.a am exempt from.the'Contractor's•License Law`.:
for the following reason(Section 703.1.5 Business and,Professions Adddlonal Sign Branch Circuits
:..
Code).. ,
Misc Conduits& Conductors' A I a
A
as ownerr 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] '3,7 a ?c
and'Professions Code). '
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J .
CONSTRUCTION LENDING,AGENCY: , .
:•I hereby. affirm that ther4 is a construction lending agency for:the I I.1 i I. �. ® a'r>_3
performance of the work for which this permit isissued(Sec 3097;- ; `'PERMIT FEE (Sub-Total) 7
CHECK
V. lzl
LA G €.tlPtiC al11.f
' P N'CHECKIN °FEE
Lenders Name
PERMIT ISSUING FEE
Lender's Address
I certif that-I have read this.a lication and. state that the above :TOTAL'FEE.
Y pp _�_ �
information is'correct. I agree;to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize2-L,1
representatives of this County to enter upon the above-mentioned
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pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sig ' ure of Permittee• D e