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Home My Public Portal About10455 LA ROSA DR_Electrical__ WORKERS'COMPENSATIONDECLARAT[ON 76A663 (2-801 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab. C.) FOR APPLICANT TO FILL IN. JOB ff`` Policy No. Company EACH NO. FEE ADDRESS v New Residential Bldgs.& Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. ��'n S% — 5 LOCALITY Multi-family Sq. Ft. NEAREST r- r� Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST G [jst' department. R OR P RMENAME Date Applicant Outlets: Rec._Light_ Sw._ MAIL First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE } PLAN CHECK a (This section need not be completed if the work Involved APPLICANT O by the permit is for one hundred dollars (5100) or less.) Lighting Fixtures First 20 ADDRESS U Total No. Additional cc I certify that in the performance of the work for which this CITY Tel No. 0 Fixed Appliances Not Over 1 HP permit is issued. 1 shall not employ any person in any manner PERMIT II'7f J so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT I-1I-r2/ G S��f �Q/V.S/ W 7 ^�� Oven _ Dryer_W.M._ ADDRESS © {V6 —� N Datrld � r�/�, A licant / �!l *. I Top _ FAU _W.H.. �' _Z 7--7— pp r�Jt Hood _ Fan _Other_ CITY ��^TF/��/� Tel No.�� 7bid NOTICE TO APPLICANT: If, after making this Certificate ot;/ Disp. — Room Air Cond._ LICENSE OR �, 'b Exemption, you should become subject to the Workers' REG. NUMBER. �yj' Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PRCE ED BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVA,or KVAR Up tot Incl. FINAL O LICENSED CONTRACTORS DECLARATION Over 1 to 101nc1. DATE /O •Z3 —�� VALIDAT N Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY ness and Professions Code, and my license is in full force and V!' effect. Services ] License Number Lic.Class 0-200 Amp. Under 600 V 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits 2 1 6 2 9 A ness and Professions Code): #.0 0 0 o e 2 Misc.Conduits&Conductors 1, as owner of the property, will do the.work and the Other (See Complete Fee Schedule)— 2 5 220 structure is not intended or offered for sale (Section - - 7044, Business and Professions Code). ` CONSTRUCTION LENDING AGENCY - o.0 0 52206 1 hereby affirm that there is a construction lending agency ( 0,21 -81 for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE , 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 lection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE �C•7-d(0 cl-/ ` Signature of Permittee Date