HomeMy Public PortalAbout6053 LOMA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 2o-ootvDPW sia7 APPLICATION FOR ELECTRICAL PERMIT O
1-hereby affirm that I have a certificate of.consent to'self CE-806G
insur0'or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a'certified copy thereof (Sec. 3800, Lab. C.) t \ +
Policy No. Company FOR APPLICANT TO FILL IN JOB /® `
Certified copy,is hereby furnished. New Residential'Bldgs. & Pools EACH NO. FEE ADDRESS
I' Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
O tion department. Multi-family Sq:Ft. — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight Sw._ AMAIL
DDRESS Q5
COMPENSATION INSURANCE. First 20 j
(This section need not be.completed,if the work involved by Total No. Additional CIT rj
a Tel. (�
the permit is for one hundred dollars (5100)or less.) PLAN CHEC
certify that in the 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.
Dote Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE'TO APPLICANT: If; after making this Certificate of APPLICATION
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
with comply with such qprov.isions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fane —Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION �/` o LICENSE OR
Disp. — Room Air Cond. Class.
I hereby affirm that I am licensed under provisions of Chapter.9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus &.Large Appliances DISTRICT NO. P O SSED BY d
and Professions Code,and my license is in full force and effect, p
Size&Type HP, KW, KVA, or KVAR �,e O O
License Number Lic. Class Up to 1 Incl. FINAL / r U
Over 1 to 10 Incl. DATE) 1�� VALIDATION
Contractor Date Over 10 to 50 Incl. `F-! O
❑ FINAL U
1 am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100
Services;Swbd., MCC & Panelboards ® fn
Date: �d70 Z
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
El Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power'Pole &Appurtenances i
HOMEOWNER-BUILDER DECLARATION _
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit __.
Law for the following -reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): zs-'
I, as owner of the property; will do the work and the Misc. Conduits&Conductors T
structure is not intended or offered for sale(Section 7044, Other.(See Complete Fee,Schedule)— 00
Business and Professions Code).
CONSTRUCTION LENDING AGENCY, ; t
I
I hereby affirm that there is.a construction lending agency for ; -3a';•.i= __
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). 111� 1,51e
PLAN CHECKING FEE
Lender's Name "
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the 'TOTAL FEE �O
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
t above-mentioned pro cty f r inspection purposes.
kk SEE REVERSE FOR EXPLANATORY LANGUAGE
ISignature 6TPermittee Date '