HomeMy Public PortalAbout5812 MUSCATEL AVE_Electrical__ i
WORKERS'COMPENSATION DECLARATION C- B 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, E-80ao6G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF,LOS ANGELES BUILDING AND SAFETY
copy thereof(tS}etc`f.�3800,Lab.C.)
0"�� �v
Policy No. � Ompany �k- K e-A- FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs.&Pools � ,EACH NO. FEE ADDRESS
LOCALITY `
ertilled copy is filed with th county building1 &2-Family,S Ft. — $
Pe inspection y' q' NEAREST
d partment. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
V FIRM CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL NAME "If �-
COMPENSATION INSURANCE Outlets:Rec Light t 2 — �C ADDRESS i ��
(This section need not be completed if the work involved by the First 20 UU �a
permit is for one hundred dollars($100)or less.) Total No. Additional Z CITY (/��G Tel No.
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in any manner so as to APPLICANT
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 PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of y
Exemption,you should become subject to the Workers'Compensation Range Heater D.W. t APPLICANT (,G
provisions of the Labor Code,you must forthwith comply with such Oven Dryer J- W.M.._ ADDRESS C[4i Ce ,
provisions or this permit shall be deemed revoked. Top FAU ,— W.H.
LICENSED CONTRACTORS DECLARATION Hood Fan a- Other_ CITY - L bk ee Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 P 0 o LICENSE ORS-�p
(commencing with Section 7000)of Division 3 of the Business and Disp. Room Air Cond. - - REG.NUMBER <0 Class C- -o
Professions Code,and my license is in full force and effect. DISTRICT NO. / PRO SED BY
Power Apparatus&Large Appliances Uy
Size&Type HP,KW,KVA,or KVAR r+-
License Number. \� Lic.Class C-1c Up to 1 Incl. FINAL 8
{b< VALIDATION Over 1 to 10 Incl. DATE FINAL Imo'
Contractor �` Date - Over 10 to 50 Incl. I -0
❑ I am exempt under Sec. Over 50 to 100 Inc. BY �
BAP.C.for this reason Over 100 pW
Date:
Services;Swbd.,MCC&.Panelboards > fn
0-200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V :s
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole&Appurtenances -
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit _
I hereby affirm that I am exempt from the Contractor's License Law C
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits AC a V
Code):
El I,r'
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 1 ITEM"
, ,
and Professions Code). TOTAL :12 -50
CONSTRUCTION LENDING AGENCY `;HECK i y 3 a 5*1
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE GI7
Civ.C.). a
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 3 00i-IL("0001 .C.rf 1-'f`.
Lender's Address C/'1 , ?,� j ��'l1�;{ (r
I certify that I have read this application and state that the above TOTAL FEE e f
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
Proper for in�purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat f PDate