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Home My Public Portal About5552 PAL MAL AVE_Electrical__ WORKERS COMPENSATION DECLARATION -ao6 10i8I APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self aCE� insure or a certificate of Workers Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec 3800 Lab C ) Policy No Company FOR APPLICANT TO FILL IN JOB PolWC Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS Ia Certified copy is filed with the county building nspec 1 8 2-Family, Sq Ft $ — $ LOCALITY -GkA - honhon department Multi-family Sq Ft — NEAREST Residential Swimming Pools CROSS ST Dote Applicant OWNER OR FIRM NAME Wr ct /"' O CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec2Light_Sw A2-- MAIL COMPENSATION INSURANCE Fret 20 -' ADDRESS(This UL(This stolon need not be completed H the work InroMd by Total No Additional CITY e-m s Tel No the permlf Is for one hundred dollars($100)or Ins ) I certify that in the performance of the work for which this APPLIC ANT M permit is issued I shall not employ any person in any manner so rn to become subject to the Workers Compensation Laws Lighting fixtures First 20 ADDRESS Total No Additional CIN Tel No Dote Applicont Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If after making this Certificate of Range_ Heater D W _ APPLIUNT 4r Y S Exemption, you should become subject to the Workers 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 _ FAU _WH _ `+AdIQN A deemed revoked Hood _ Fon _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 REO NUMBERq !59Class G- (commencing with Section 7000)of Division 3 of the Busineu Power Apparatus 8 Large Appliances DISTRICT NO PROCE BY r and Professions Code,and my license is in full force and effect y CLIC Size 8 Type HP KW KVA or KVAR �- 0 License Number y S� o Lic Class G' � Up to 1 Incl V T p FINAL Contractor�lcV/h 4t9W5 a1.7g- I O� Over 1 to IO Incl DAA '��-�¢ VALIDATION 0 ❑ CI- Over 10 to 50 Incl FINAL I am exempt under Sec Over 50 to 100 Inc BY 6 B 8P C for this reason Over 100 Dote Services Swbd MCC 8 Panelboa ds ► /J 0 -200 Amp Under 600 V Signature 201 - 1000 Amp Under / ❑ Over 1000 Amp or Over 600 V Exemption for Reg Molest Elect SINGLE FAMILY Temp Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor s Liceme Additional Sign Branch Circuits r 3 4 4 4 A Law for the fallowing reason (Section 7031 5 Business and Professions Code) ❑ I as owner of the property will do the work and the Mia Conduits 8 Conductors �• • • • 2 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► ( • • 3 2 Q 0 7044 Business and Professions Code) • • • 3 2 Q CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 0 8 1 4—8 4 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec 3097 Ctv C ) PLAN CHECKING FEE Lenders Name PERMIT ISSUING FEE Lender s Address I certify that I hove read this application and state that the TOTAL FEE above information is coined I agree to comply with all County ordinances and State lows regulating Electrical wiring and hereby authorize represe gqhves of this County to anter upon thea ve mned pr. 6rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permit ee Date