HomeMy Public PortalAbout10465 LA ROSA DR_Electrical__ { 07''// �
WORKERS'COMPENSATIONDECLARATION 63
CE8O6G 12801 APPLICATION FOR .ELECTRICAL PERMIT
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I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES r/�� BUILDING AND SAFETY
insure,or a certificate,ol Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, Lab. C.) ,
FOR,APPLICANT TO FILL IN JOB ��11
Policy No. New Residential Bldgs.&Pools
Company EACH NO. FEE ADDRESS �ry .,/1 O � DIE
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. 14 4U $,62 — $ LOCALITY
❑ -
Certified copy is filed with the county building inspection Multi-family Sq. Ft. NEAREST CROSS ST L{,)
department. Residential Swimming Pools OWNER OR
FIRM NAME VLP
Date Applicant Outlets: Rec.—Light— Sw._ MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.
COMPENSATION INSURANCE d
PLAN CHECK O
(This section need not be completed if the work involved APPLICANT U
by the permit is for one hundred dollars (3100) or less.) Lighting Fixtures First 20
Total No. Additional ADDRESS O
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. U
permit is issued, I shall not employ any person in any manner PERMIT L)
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. _ APPLICANT A4 !N ALA' d
Oven _ Dryer_W.M. ADDRESS
Date 40 /9 Top _ FAU _W.H. _ z
kJ /9 Applicant 0 V n '0 _
' Hood — Fan _Other_ CITY 'V 'C Tel No.
NOTICE TO APPLICANT: If, after making [his Certificat Disp. _ Room Air Cond.— LICENSE OR L J
Exemption, you should become subject to the Wo ers' REG. NUMBER�O Y Class G L./
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED BY
with comply with such provisions or this permit shall be
deemed revoked. Size& Type HP, KW, KVA,or KVAR Q (/
Up to 1 Incl. 0
FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl ! � VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL r
9 (commencing with Section 7000) Division 3 the Busi- By
Over 100
nest and Professions Code, and my license is in full
force and
effect. Services
License Number 304f Lic.Class &^/0 0-200 Amp. Under 600 V �i • / /v
201-1000 Amp. Under 600 V
Contractor Pste Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that 1 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
ness and Professions Code): �9 1 8 Q 4 A .
Misc.Conduits& Conductors
1, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— # a e o o e 2
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 2 a to 4 a 1 Q
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency e o o q a, 1 C
for the performance of the work for which this permit is PERMIT FEE ISub-Total)
issued (Sec. 3097,Civ.C.). /0 1 1.0 2 —81
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
1 certify that I have read this application and state that the TOTAL FEE - F4 k)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 inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
1222 ic ln7nfsi
Signature of Permit'Ke Date