HomeMy Public PortalAbout9578 LOWER AZUSA RD_Electrical__ WOCOMPENSATION DECLARATION 7&6,663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
I herdby affirmrm that I have a certificate of consent to self O
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certif'i'ed copy the qf( � La )
Polic N� iCbr�pdn% FOR APPLICANT TO Flll IN JOB p
QCertified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE
ADDRESS S 7 Q o c•�e r z u
❑Certified copy is filed with the county building inspeF 1 &2 Family Sq Ft $ = $ LOCALITY
tion d2portment Multi family Sq Ft NEAREST
CROSS `Nt �� e� r✓l
ate .1 Applican
Residential Swimming Pools OWNER OR ��pp
FIRM NAME
CERTIFICATE OF EXEMPTION ROM WORKERS Outlets Rec--Light Sw Z MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed It the work involved by First CITY Tel No
the permit Is for one hundred dollars(=100)or less) Total No Additional
PLAN CHECK
I 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
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICATION GS 9 SAI b e �ttC v
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 ADDRE St ' B
with comply with such provisions or this permit shall be Top — FAU —W H Z Q
deemed revoked Hood — Fan —Other �t7 CI 4c Vy Tel Nq�(p
LICENSED CONTRACTORS DECLARATION o`"/ LICE OR
Disp — Room Air Cond � B 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 PR SSED BY d
and Professions Code and my license is in full force and effect
Size&Type HP KW KVA or KVAR O
License Numbe ex Lic Class C—/b — I _ Up to 1 Incl FINAL
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����, G&E Da VALIDATION Cr
. - Z Over 1 to 10 Incl DATE 6- 2,3-42-,
Contracts to Over 10 to 50 Incl U
❑ FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 d
Dat Services Swbd MCC&Ponelboards , Z
0 200 Amp Under 600 V
Signatureor ReOver 1000 Amp or Over 600 V 201 1000 Amp Under 600 V
❑ Exemptio fg Ma�nt Elect �
SINGLE FAMILY Temp Power Pole&Appurtenances _
HOME OWNER BUILDER DECLARATION i ,n s
1 hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuiti!ic i s
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits -c-
Professions
cProfessions Code)
❑ Misr Conduits&Conductors ITS`'
I as owner of the property will do the work and the
1
structure is not intended or offered for sale(Section 7044 Other(See Complete Fee Schedule)_ , Ti Q AL 75T ® v '
Business and Professions Code) ( c -7
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHANGE IJO
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) dZ
(Sec 3097 Civ C )
PLAN CHECKING FEE M-NO1 3/ c/9�
Lender s Name
PERMIT ISSUING FEE 2061 1 AM 9 w
Lender s Address
1 certify that I have read this application and state that the TOTAL FEE
above information is correct 1 agree to comply with all County
ordinances and State jaws regulating Electrical wiring and
9 hereby authorize representatives of this County to enter upon
V
e ab ve;C-imntioned proper for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig lure of Permittee ��Date V 7Z, SEE