HomeMy Public PortalAbout6038 MUSCATEL AVE_Electrical__ '+ VtaRKFRS'COMPENSATION DECLARATION T00019DPW 3 87 ����] �(� i��B®Il Ej FOR 1���/ [� RICAL PERMIT
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,,y�,helebf,,affirm Tlwt P have a'certificate of consent to self CEAZWG k� �'j[�`� \lam
. sure, or.a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No./.-I TE& Company Um^f FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO FEE ADDRESS C' I S
❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department. ' Multi-family Sq. Ft. — NEAREST
CROSS ST
Dote — �' Applicant 'WI f.'N (�} Residential Swimming Pools OWNER OR
FIRM NAME •6 •fn I
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_�C_) Light_a__Sw._�L MAIL
COMPENSATION INSURANCEDDRESS
(This section need not be completed if the work involved by NFirst 20 CITY Tel. No.
Total 7g
the permit is for one hundred dollars($100)or loss.) o. Additional f
PLAN CHECK
I certify that in 'he performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws.
Additional
Total No.� CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate ofpp APPLICATION N e G
Exemption, you should become subject to the Workers' Range— HeaterJ—D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. — PW 14 kC e
deemed revoked. Hood — Fan —Other— CITYL. Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR t
. Class.
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REGNUMBER r2
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY d
and Professions Code,and my license is in full force and effect.
�� Size&Type HP, KW, KVA, or KVAR U
License Number S 6 Lic. Class___C� Up to 1 Incl. FINAL
cc
Over 1 to 10 Incl. DATE — VA ATION
Contractor 'C�'�S� Date
❑ Over 10 to 50 Incl. FINAi 1--
I
I am exempt under Sec. Over 50 to 100 Inc. gY U W
B.&P.C. for this reason Over 100 d
Services, Swbd., MCC&Panelboards ZZ
Date: 0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V `G L 9 4 A
SINGLE FAMILY Temp. Power Pole&Appurtenances #1 0 0 0 o c 2
HOME OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ( o - .3(150
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): C O G S 0,:1 C c=.
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors () 7.2 8 8
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
r f PLAN CHECKING FEE
Lender's Name��- 7f71 X35 !, •--
PERMIT ISSUING FEE
Lender's Address 0.7�%
0
I certify that I have rea this application and state that the TOTAL FEE a!f
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
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig oture�of ermitt D to