HomeMy Public PortalAbout6384 OAK AVE_Electrical__ wORKEk-3FCOMPkNSATION DECLARATION. 7BA8663 06G (2.80). 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'qqmpensation Insurance r / te'
r ere fc.380 ab.C.) �19,,Y?l +�
PbR, co74��`�Cbm� FOR APPLICANT TO FILL IN JOB
4
New Residential Bldgs. Poo s EACH NO. FEE ADDRESS
❑ Certified co hereby furnished. $ — $ E_& LOCALIT
PY' �.,_ '' 1 &2-Family,Sq. Ft.
C3 Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
dep tm nt. Residential Swimming Pools OWNER OR G
Outlets:Re�Light�Sw. L FIRM NAME
Date � Applican MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. 9 }
COMPENSATION INSURANCE
PLAN CHECK CL
APPLICANTO
(This ,section need not be completed if the work involved U
by the permit is for one hundred dollars ($100) or less.) Lighting F•ixt res First 20 ADDRESS
Total No. Additional O
I certify that in the performance of the•work for which this CITY Tel No.
Fixed App'ances Not ver 1 HP
permit is issued, I shall not employ any person in any manner /� PERMIT W
so as to become subject to the Workers'Compensation Laws. Range Heater D.W. _ APPLICANT a
Oven Dryer W.M. ADDRESS Z
Date Applicant Top _L FAU Z W.H.._
Hood �/ Fan _Other_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp.17 Room Air Cond,_.
Exemption, you should become subject to the Workers' REG.NUMBERefi Pl1q,7class l v
Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliances DISTRICT NO. P E ED BY
with comply 'with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR r
Up to 1 Incl. � O
FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. CGS"0 � VALI DATI N
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. Services Jp-
�— U 0-200 Amp.Under 600 V U
License Numb r ,r �Li�.Glass 201-1000 Amp.Under 600 V
Contrscto ` ante Over 1000 Amp.or Over.600 V ,
• 1 •
HOME OWNER-BUILDER DE LARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am Sign with One Branch Circuit exempt from the Contractor's Additional Sign Branch Circuits
License Law for the following reason (Section 7031.5, Busi-
-ness and Professions Code):
Misc.Conduits&Conductors
❑ I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— L 2 3 8 5 A
structure is not intended or offered for sale (Section
7044,Business and Professions Code), { u o 0 0 0
CONSTRUCTION LENDING AGENCY 2
�I hereby affirm that there is a construction lending agency 0 0 39.7 0
for the performance of the work for which this' permit is PERMIT-FEE (Sub-Total) 0 i
issued(Sec.309.7,Civ.C.).• 0 c. 0 5 y
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE s,Ci 1 21 8:-- `C; 1
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 State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the ovei entione��rop rty for inspection purpo s. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee /Datht