HomeMy Public PortalAbout5233 PAL MAL AVE_Electrical__ / I
,v ORICrthc COMPENSATION DECLARATION C6A� 10/81 APPLICATION FOR ELECTRICAL PERMIT
I herekl+t;,affe'm that`I have a certificate of consent to self CE-8066
ffisuYe, o alecertifieat�of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified§bpy thereof(Sec. 3800, Lab. C.)
Policy No, Company FOR APPLICANT,TO FILL IN JOB
Certified copy Is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
❑
Certified copy is filed with the county building inspec- 1 $2-Family, Sq. Ft. $ — $ LOCALITY
'NEAREST
Tion department. Multi-family Sq. Ft.
CROSS ST.
Residential Swimming Pools O
FIRM NA
Date Applicant M
FIRM NAME '
CERTIF;CATE OF EXEMPTION FROM WORKERS' LL_Sw•1� +MA1L
COMPENSATION INSURANCE Outlets: Rec�LLight ADDRESS
tThis section need not be eom leted if the work Involved b First 20
he permit is for one hundred dollars($100)or less.) Y Total No. Additional, 2. CITY C' Tel. No.
PLAN CHECK
I certify that in the,performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to-the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
r �/ Additional /10
Date Applicant Lj61:ft; ..A&L-I L Total No. _ CITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP_ APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater D.W.
Compensation provisions of the Labor Code, you must forth- Oven _Dryer W.M. ADDRESS
with comply with such provisions or this permit shall be Top EAU —W.H. —
deemed revoked: Hood _ Fan _Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
'I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PRO S D B.Y
and Professions Code,and m license Win full force and effect: Power Apparatus&Large.Appliances !'
y Size&Type HP, KW, KVA, or KVAR' ✓
License Number Lic.Class Up-to 1 Incl. FINAL
Contractor Date Over 1 to 10'incl. DATE :A
.Q VALIDATION
❑ Over 10 to.50 Incl. FINAL U
I am exempt under Sec. Over 50 to 100 Inc. BY
tZl It
B:BP.C. for this.reason.. Over 100 FA
Date: Services', Swbd., MCC 8 Panelboards 2�� 9'A
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over'1000 Amp. or Over 600 V # o o'.o 0 02
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances o - 7600
HOME OWNER-BUILDER,DECLARATION Sign with One Branch Circuit o - o76006
I hereby affirm that I am exempt from the Contractor's License Additional Sign:Branch Circuits
Law for the following reason (Section 7031.5, Business and 2 2 —$4
Professions Code):
IDI, as owner of the property, will'do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE fo
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify. that 1 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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date