HomeMy Public PortalAbout6350 OAK AVE_Electrical__ r WO{ I{ERS'COMPENSATION DECLARATION CE-803. 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 rdfied copy thereof(Sec.3800 Lab.C.)
CN-o.
ff (4 FOR APPLICANT TO FILL IN
P -I cy No. 10 Compan.14,S C' 1i • JOB J` ��
New.Residential Bldgs, ools. EACH NO. FEE ADDRESS (J
,❑ Certified copy is hereby furnished. 1 &2=Family,Sq. Ft( °r' $ ?D — $ .2Ca LOCALITY
Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST Gc�
department. g /,/ OWNER OR
Date •.Applicant-// ' G � Outlets:•Re ight y Sw. /J FIRM NAME// AA tS��', //��.�$.�' /
First 20
ADDMAIRESS 17ZO— J kk_
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Addi.ti al CIT Tel No.
COMPENSATION INSURANCE -
PLAN•CH E O.
(This section need not be completed If the work involved APPLICANT OCA
by the permit is for one hundred dollars,($100) or,less.) Lighting Fixtures first 20 ADDRESS
Total No. Additional
I'certify that iii the performance of the work for which this CITY Tel No.,
Fixed Appliances t ver 1 HP O
permit is issued, I shall not employ any person in any manner V • ✓ PERMIT W
so as to become subject to the Workers'Compensation Laws. Range He er_ .W,_ APPLICANT a
Oven er_ M. _qj CO)
ADDRESS
Date Applicant Top FA U ✓W. .
'Hobd Fan _.0th r_ CITY Q�I'� t Tel No. JI
NOTICE TO APPLICANT: If, after making this Certificate of Disp _Room Air Cond_ LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Cl...-a-16
Compensation provisions of the Labor Code;you must forth- Pow r Apparatus&Large Appliances DISTRICT NO. PROC SED`BY
with comply with such provisions or this permit shall be Size Type HP,KW,KVA,or KYAR �ia
deemed revoked. Up to 1 Incl.
r Over 1 to 10 Incl. FINAL
DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. 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 d+
ness and Professions,Code, and-my license is in full force and
effect. Services
3SL0I y7 0_,:-,)U 0-200 Amp.Under 600 V
License Number qq�� Lic.Class201•-1000 Amp.Under 600 V
Contractor%�'u`�'m1w 11GC41i 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 follopving reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): '
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other(See.Complete Fee Schedule)— 3 C'
structure is not intended or offered for sale (Section y` c 0 0 0 o C
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY 20 039.7 0I hereby affirm that there is a construction lending agency
for the performance of the work for which 'this permit is PERMIT FEE (Sub-Total)
issued(Sec.3097,Civ.C.). �� Q o 0 r; -4 ti %f,',r ,�
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) G �8'2
tender's Address PERMIT ISSUING FEE To
I certify that I have read this application'and state that the TOTAL FEE7d
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 a ve-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Elife