HomeMy Public PortalAbout6034 MUSCATEL AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 78-803 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm•that I have a certificate of consent to self insure, CE-808G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy,No. Company FOR APPLICANT TO FILL IN JOB O L
❑ ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE c
❑ Certified copy is filed with the county building inspection ,
1 & 2-Family,Sq.Ft. $ $ LOCALITY 1
NEAREST
department. Multi-family Sq.Ft. CROSS ST. C
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATEOF EXEMPTION FROM WORKERS' MAIL
Outlets:Rec .Light—Sw.—
COMPENSATION INSURANCEADDR ESS
First 20
(This section need not be completed if the work involved by the Total No."f '�"� Additional CITY Tel.No.
permit Is for one hundred dollars($100)or less.) PLAN CHECK
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
Additional
Total No. CITY Tel.No.
Date .Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU W.H.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 D'is . — Room Air Cond. LICENSE OR Class.
(commencing with Section 7000)of Division 3 of the Business and p REG.NUMBER.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT
NO. PROCESSED 6 d
Size&Type HP,KW,KVA,or KVAR —!5r. 0 _ Q
License Number Lie.Class Up to 1 Incl. FINAL / V
Over 1 to 10 Incl. DATE O+ �S VALIDATION Q
Contractor Date Over 10 to 50 Incl. FINAL If U
❑ I am exempt.under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 — U"
U)
Services,Swbd.,MCC&Panelboards Z
Date: 0-200 Amp.Under 600 V J
Signature 201 - 1000 Amp;Under 600 V
❑ 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
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Co ): 02
Misc..Conduits&Conductors RCT a
I,as owner of the property,will do the work and the structure A
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)._
and Professions Code.). > 3303 85.60
CONSTRUCTION LENDING AGENCY 1 ITEM
I hereby affirm that.there is a construction lending agency for the TOTAL 80-5-60
performance of the work for which this permit is issued(Sec:3097, PERMIT FEE (Sub-Total) 30 CHECK
/�}► Q (�
Civ,C.).
CHECK 85060
PLAN CHECKING FEE
Lender's Name CHME °OO
PERMIT ISSUING FEE oZ� 30
Lender's Address
I certify that 1 have read this application and state that the above TOTAL FEE6o M-CM1 10/12/95
information is correct.1 agree to comply with all County ordinances
and State Laws regulating Electrical wiring, and hereby authorize 2794 1 PH 30021
representatives of this County to enter upon the above-mentioned
property for Inspecti I purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ign ure of Per a Da e