HomeMy Public PortalAbout6374 OAK AVE_Electrical__ :,,WORKERS'COMPENSATION DECLARATION ctabS . APPUIcA.TION .FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate 'of consent to self COUNTY OF LOS ANGELES 'BU DING AND SAFE]�Y'
insure,or a certificate of Workers'Compensation Insurance,or �+ r `
a certified copy thereof(Sec.3800,Lab.C.) i W.sl /
FOR APPLICANT TO FILL IN JOB Q
Policy No. Company ADDRESS
New Residential BI'dgs.&Pools EACH NO. FEE
CertifieS'copyls hereby furnished. 1&2-Family,Sq. Ft.` $ — $ LOCALITY
® Multi-family Sq. Ft. — NEAREST/ n
Certified.copy is filed with the county building inspection
dap tm nt. 1 Residential Swimming Pools CROSS ST G
OWNER OR
r� AFIRM NAME
Date Applicant Outlets: Rec.,--Light Sw. M
� , { �
First 20 ADDRIESS le
CERTIFICATE OF EXEMPTION.FROM.WORKERS' Total No. Additional CITYTel No..
COMPENSATION INSURANCE67
I' }
PLAN CHECK 0.
' ] APPLICANT
(This section need not be completed if the work involved Lihting Fixtures First 20 ?0 U
by t e permg
it is for one hundred dollars .($1.00) or less.) ADDRESS
Additional
Total No. _ Q
I certify that in the performance of the'work for which thisFixed App .Not Over 1:HP CITY Tel No.
liances
.permit is.issued, I shall not employ any'person in any manner 1 'PERMIT
sofas to become subject to the Workers'Compensation Laws. Range_Heater W D.W. _ APPLICANT GI' s- W
Oven --Dryer—W.M._ ADDRESS 2Ulu/!/�/� �� Z
Date Applicant Top _ FAU _W.H.,_ G —
Hood —Fan _Other_ CITY M0A1,,PLV Tel No. rJ _
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond— LICENSE OR nn
Exemption, you should become subject to the Workers' REG.NUMBER 3..-/ Class 1:+")O ;
Compensation:provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
with comply with .such provisions -or this permit shall be
deemed revoked: Size&Type HP,KW,KVA,or KVARC7`�S _�
I Up to 1 Incl.
FINAL, —,go Z.
Over'1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION: i VALIDATION
' Over 10 to 50 Incl.
. .
I hereby affirm that I am licensed under.provisions of Chapter Over 50 to 100 Inc. FINAL'
BY �•.
9 (commencing with Section 7000)of Division 3 of the.'Busi Over 100 �'.
ness and•Professions,Code,and my license is in full force and
effect.
Services
� 0-200 Amp.Under 600 V
License Number 340147 Lic.Class /0
��JJ I' 201-1000 Amp.Under 600 V
Contractor GF, Date .. Z Over 1000 Amp.or-Over 600 V.
' HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances 2 3 a 3 A
I hereby affirm that I am exempt from the Contrac'tor's Sign with One Branch Circuit ' # 0'0 0 0 ,0 2
License Law for the following reason (Section 7031.5, busi- 'Additional Sign Branch Circuits 2 0 0 3 3
ness and Professions-Code):
]Misc.Conduits&Conductorso o;'o 4,3.0 v
Ell, 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 l2, 1 8 81
7044.1 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) /� Ire
issued(Sec.3097,Civ.C.). a
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE -
I certify that I have read this application and state that the TOTAL FEE - i
above information is correct.I agree to comply with all County
ordinances and State lades regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the b ve-entione�r perty for-inspection pumpas/
SEE'REVER•SE FOR EXPLANATORY LANGUAGE
Signature of Permfftee ate