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HomeMy Public PortalAbout6247 KAUFFMAN AVE_Electrical__ • WORKERS' COMPENSATION DECLARATION 20-0019 DPW 3/87 76,663 APPLICATION FOR ELECTRICAL PERMIT O _-• I hereby affirm- that I have a certificate of consent to self CE-e06G 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.)C- Policy No.B1516�• Company STAlr1� FOR APPLICANT TO FILL IN JOB /� V ❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS `7 ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY TrM�(� C — NEAREST / ONGD� tion d portment. Multi-family Sq. Ft. CROSS ST. !� _I, �j �,Wlj�`• Residential Swimming Pools Dc ��.n/u Date �I Applicant�?� OWNER NAME J TI[�tiT7 OR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec&-Light j SW.— MAIL c D �'� � 4 / COMPENSATION INSURANCE z�(1 J!' ADDRESS 7 Vr Total (This section need not be completed if the work involved by No. Additional l CITY Tel. No.g 101035 155 the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in 'he 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 Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION:3AI2 CON-*,, Exemption, you should become subject to the Workers' Range— Heater—D.W. — ^^ Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 4 t IS-r. with comply with such provisions or this permit shall be Top — FAU —W.H. deemed revoked. Hood — Fan —Other REG. NUMBCITY [ 5(h� Tel. No.?I 6f.L7 LICENSED CONTRACTORS DECLARATION JW1 LICENSE OR ER q9 Class. B I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Conal. (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PRO SSED BY d and Professions Code,and my license is in full force and effect. t� f Size &Type HP, KW, KVA, or KVAR ©� o License Number _'-1Q`�� Lic. Class Q� Up to 1 Incl. FINAL U r � � - C�� Date �8 q Over 1 to 10 Incl. DATE �! VALIDATION 0 Contracto F1oO Over 10 to 50 Incl. Gn �P I— FINAL U I am exempt under Sec. Over 50 —_to 100.1nc. BY W B.&P.C. for this reason Over 100 d Services, Swbd., MCC& Ponelboards oil. Z t1D 0- 200 Amp. Under 600 V Signature D 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. M Over 1000 Amp. or Over 600 V nt. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION ^^•" z Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Sig •-, Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits =r1„ Professions Code): �,- ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 23 _F structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ pool ) - ; ;_ s•-•r• I f Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CHANGE the performance of the. work for which this permit is issued PERMIT FEE (Sub-Total) v (Sec. 3097, Civ. C.). PLAN CHECKING FEE 3 i 0 7,�10v' 1 Lender's Name •1 r. Lender's Address PERMIT ISSUING FEE g• ^ 9.,5: - A t T 1 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 thorize representatives of this County to enter upon the ab mention p rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Signature oftrmittP4 Date