HomeMy Public PortalAbout9933 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION 79-883 ,o,e, APPLICATION FOR ELECTRICAL PERMIT 1{�
I hereby affirm
Gm that 1 have a certificate of consent to self insure, - �J
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(SAcc38020t'Lab C)
Policy NO 0-0Company r& "'3 ' -" 4fr FOR APPLICANT TO FILL IN JOB
ADDRESS E✓ F4ZLL
❑ Certified copy is hereby fumlahed New Resndentnal Bldgs & s EACH NO FEE
Certified copy is filed with t county budding Inspection 1 & 2-Family,Sq Ft � $ _ $ LOCALITY C e
department Multi-family Sq Ft NEAREST
CROSS ST
Date Applicant Residential Swimming Pools OWNER OR
FIRMNAME LCAA
RTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec—Light_ Sw MAIL is "� Ham
COMPENSATION INSURANCE
(This section need not be completed If the work involved by the First 20
Total No Additional CITY Tel No
permit is for one hundred dollars($100)or lose) —2
PLAN CHEC
I certify that in the performance of the work for which this permit
APPLICANT
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
Total No Additional CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT If, after making this Certificate of =LM
Exemption,you should become subject to the Workers'Compensation Range_ Heater DW _ APPLICANT
provisions of the Labor Code.you must forthwith comply with such Oven _ Dryer_ W M _ ADDRESS (plZ tLa
provisions or this permit shall be deemed revoked Top _ FAU _ WH _
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ CITY C Tel No _a
I hereby affirm that I am licensed under provisions of Chapter 9Dnsp — Room Air Cond LICENSE OR C CFasa C p
(commencing with Section 7000)of Division 3 of the Business and REG NUMBER
Professions Code,and my license Is in full force and effect
Power Apparatus&Large Appliances DISTRICT6,
0 B
ja Sae&Type HP,KIK KVA,or KVAR i 0e
License Number. `— Lx: Class C— Up to 1 Incl FINAL
ate Over 1 to 10 Incl DATE �� 0
Contractor �'�FL�� — 3.. v VALIDATION Q
❑ Over 10 to 50 Incl F
FINAL -
I am exempt under Sec Over 50 to 100 Inc BY ��i%y CCS)
BAPC for this reason Over 100 �J PLN
Date Services,Swbd,MCC&Panelboards ► Z
0-200 Amp Under 800 V
Signature 201 - 1000 Amp Under 800 V
❑
ExemptOver 1000 Amp or Over 600 V
Exemption for Reg Mannt Elect
SINGLE FAMILY Temp Power Pole&Appurtenances 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law ACCT.&v
for following reason(Section 70315,Business and Professions Adddlonal Sign Branch Circuits 3307124
.95
El1,as owner of the property,will do the work and the structure Misr Conduits&Conductors 1 ITEMS li
is not intended or offered for sale (Sedan 7044, Business Other(See Complete Fee Schedule) _
and Professions Code) Poo. TOTAL 124.95
CONSTRUCTION LENDING AGENCY CECK 124-95
1 hereby affirm that there is a construction lending agency for the .00performance of the work for which this permit is issued(Sec 3097, PERMIT FEE (Sub-Total)
CKVRCiv C)
Lender's Name PLAN CHECKING FEE 0000—Ml 8/13/90
PERMIT ISSUING FEE
Lender's Address 7368 1 AM1O:49
I certify that I have read this application and state that the above TOTAL FEE
information is cored I agree to comply with all County ordinances
and State laws regulating Electrical wrong, and hereby authorize
representatives of this County to enter upon the above-mentioned
prop for mspedan urposea SEE REVERSE FOR EXPLANATORY LANGUAGE
5-�3-
Signa ure of Permittee Date