The URL can be used to link to this page

Home My Public Portal About6047 OAK AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION + ;CE-86 APPLICATION FOR ELECTRICAL PERMIT' I hereby-affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or ( " a certified copy thereof ec.3800, a .C l� sp//„"t f FOR APPLICANT TO FILL IN JOB jy� ,9R� Po�lidyo. ompany ADDRESS �f (�/New Residential'Bldgs.&Pools EACH NO. FEEtified copy is hereby furnished. 6 � 1 &2-Family,Sq. Ft. $ — $ LOCALITY Multi-family Sq.Ft. — NEAREST �' Certified copy is filed wathoty 2ding ins'ectio CROSS ST department. Residential Swimming Pools OWNEROR/ FIRM NAMEDate_j Applicant ��ff//� Outlets: Rec.. Light ! Sw. AIL First 2� ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY ;� Tel No. a } COMPENSATION INSURANCE p, PLAN CHECK CL PPLICANT V (This •section need not be completed if the work involved �� - by ,the permit is for one hundred dollars ($100) or'less.) Lighting Fixtures First 20 ADDRESS Total No.– Additional O I certify'that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY ' ti el No. permit is issued, I shall not employ any person in any manner PERMIT e� IJJ so as to become subject.to the Workers'Compensation Laws. Range_Heater D.W. APPLICANT Oven — Dryer_W.M. ADDRESS 11, /hQ N Z Date Applicant. Top _)FAU _W.H.,_ ; Hood Fan _Other_ CITY e, Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Condom LICENSE OR = :�. Exemption, you should-become subject to the Workers' REG.NUMBER Class Compensation provisions of the Labdr Code,you must forth- Power Apparatus&.Large'Appliances DISTRICT NO. \ PR S . . BY with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR /7 deemed revoked. I A� T Up to.1 Incl. FINAL Over 1 to 10 Incl, DATE' � p LICENSED CONTRACTORS.DECLARATION Over 10 to 50 Incl. �'�(r� VALIDATION I hereby affirm that I.am licensed under provisions of Chapter Over 50 to 100 Inc. .FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- Over,100 BY ness and Professions.Code;and my license is in full force and , effect. J Services" License Number Lic.Class �/ 0-200 Amp.Under 600 V It 201-1000 Amp.Under 600 V AAzrwwContra � ��n`�Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances - I hereby affirm that I am exempt from the Contractor's Sign with One.Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits nessand Professions Code): Misc.Conduits&Conductors © I, as owner of the property, will do the•work and the Other(See Complete Fee Schedule)— + ” structure is not intended or offered for sale (Section ' r_ 7044,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 PERMIT FEE (Sub-Total) -•� 6"7w j` 'I issued(Sec.3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) �` :;• r�- Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE above information is correct.I agree to comply with all County , ordinances, and to laws're ulating Electrical wiring, and hereby aut tz esentat' es f this County to enter upon the abo me prope y ection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ) Signature of Permitt a Date