HomeMy Public PortalAbout9104 OLIVE ST_Electrical__ RKEA 'COMPENSATION'DECLARATION ' 74A683 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.) )
` FOR APPLICANT TO FILL IN JOB
$olicy'No. Company EACH NO. FEE ADDRESS
- N4w Residential Bldgs.&Pools
O Certified copy is hereby furri 1 &.2-Family,Sq.Ft. $ — Is LOCALITY
❑ Multi-family Sq.Ft. NEAREST
Certified copy' with the county building inspection CROSS ST
departme Residential Swimming Pools OWNER OR
FIRM NAME
Date Applicant Outlets: Rec.^L'i,ght Sw. MAIL /®
First 20 ADDRESS
CERTIFICATE.OF EXEMPTION FROM WORKERS' Total No. Additional
COMPENSATION INSURANCE , CITY Tel No. }
PLAN CHECK d
APPLICANT O
(This section need not lie completed if the work involved Lighting Fixtures First 20 V
by-the permit is for one-hundred dollars ($100) or less.) ADDRESS (:
Total No. Additional 0
I certify that, in the performance of the work for which thisCITY Tel No. l—
permit is issued, I shall not employ any person In any manner Fixed Appliances Not Over 1 HP
PERMIT
so as to ecome subject:to.the Workers'.Compensation'Laws. Range_Heater D.W._ APPLICANT a
G N
' Oven _ Dryer_W.M,._ ADDRESS � Z
Dat pplicant Top _ FAU —W.H..
Hood _ Fan _Other— CITYaaef!�
Tel.No..
NOTIC TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond.— LICENSE O'R' / ^<
Exemption, you should become subject to, the Workers' ' REG.NUMBER /v Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliances DISTRLCT NO. PROCE9fEPBY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP.,KW,KVA,or KVAR
Up to 1 Incl. 'Q
'FINAL
Over 1 to 10 Incl. r7 DATE VALID ;PION
LICENSED CONTRACTORS DECLARATION•• Over 10 to 50 Incl. �
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINA
9 (commencing with Section 7000)of Division 3 of the Busi- Over 1.00 BY
ness and Professions.Code, and my license is in full force and
effect. ? Services
License Numbe ✓ r—Z—Lic.Clas 0-200 Amp.Under 600 V
eems�]] � 201-1.000 Amp,Under 600 V
Contract���/ Dat Over 1000 Amp.or Over 600 V'
HOME OWNER-BUILDER DECLARATIO_ Temp.Power Pole&Appurtenances 2 9 4.7
I hereby affirm that I am exempt fro he Contractor's Sigr?with One Branch Circuit # 0 0 0 0 0
License Law for the following reaso 'action 7031.5, Busi-. Additional Sign Branch Circuits 3250
ness and Professions Code):
Misc.Conduits&Conductors
I,,. es owner of the pr rty, will do the work and the Other(See Complete Fee Schedule)— o 0 032500
=
structure is not into
nt_ ded or offered for sale (Section
7044,Business an3VProfessions Code).
CONST CTION LENDING AGENCY p 9. 18 8 5
I hereby affirm at,.there is a construction lending agency
for the perf ance of the work for which this permit is PERMIT FEE (Sub-Total)
issued(Se 097,Civ.C.).
Lender' arae PLAN CHECKING FEE (One-Fourth Permit Fee)
Le er's Address_
ddress PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE 3 z
above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representative of this County to enter upon
the ab e-rn tinned property tins 'action p poses. SEE-REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date