HomeMy Public PortalAbout5426 PARMERTON AVE_Electrical__ WORKERS COMPENSATION DECLARXTION 176 CE-806G 12 801° APPLICATION ,FOR ELECTRICAL PERMIT
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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'Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C t '
�����yy./��� FOR APPLICANT TO FILL IN JOB /
Policy Natl�'�fL1JCom pan EACH NO FEE ADDRESS O C
❑ New Residential Bldgs &Pools ,
Certified copy is hereby furnished 7 $2 Family,Sq Ft $
— $ LOCALITY
NhAmtbi
Certified co
Multi family Sq Ft
VO copy is with the county building inspection CROSS ST
depa ent Residential Swimming Pools _ OWNER OR
�/J T FIRM NAME
Dat �pphcant4 �" ]�(x-L/�/il�+ Outlets Rec�Li9ht5w (jam MAIL
> First 'ADDRESS
CERTIFIC TE Of EXEMPTION FROM WORKERS' Total No _/_-.p_ Additional CIT Tel No >.• COMPENSATION INSURANCE jy
PLAN CHE Q
APPLICANT U
(This section need not be completed ifvthe work involved Lighting Fixtures First 20 6D ADDRESS
by the permit is for one hundred dollars ($100) or less) � Additional y It
Total No —
1 certify that in the performance of the work for which thisCITY Tel No F—
permit us issued 1 shell not employ any person in any manner Fixed Appliances Not Over 1 HP U
PERMIT
so as to become sublett to the Workers' Compensation Laws Range_ Heater—D W APPLICANT d '
Oven _ Dryer W M _ ADDRESS Z
Top FAU'_W H _
Uale Applicant \
t Hood Fan [her_ CITY tJ Te o ..� -r
NOTICE TO APPLICANT If after making this Certificate of Disp _ Roomond_ i LICENSE OR
Exemption you should become subject to the Workers' REG NVMBE Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PRO ESS D BY
with comply with such provisions or this permit shall be '
deemed revoked Size& Type HP KW KVA or KVA r 4FS' �.
Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE
LICENSED CONTRACTORS DECLARATION Over 10 t0 50 Incl" /110 -Z6-9111 VALIDATION
FINAL
1 hereby affirm that 1 am licensed under provisions of Chapter. Over 50 to 100 Inc
By --
9 (commencing with Section 7000) of Division 3 of the Bust Over 100
ness and Professions Code and my license is in full force and n �j+
effect �ias�y /y Services _ c.J�
License Numbe Lie Class ZD 0 200 Amp Under 600 V Vn(1
201 1000 Amp Under 600 V
Conto( r; �_ Over 1000 Amp or Over 600 V
HOME NER BUI ER DECLARATION Temp Power Pole& Appurtenances
1 hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Bum Additional Sign Branch Circuits
ness and Professions Code)
Misc Conduits& Conductors 3 X 0 b 0
I as owner of the property will do the work and the Other(See Complete Fee Schedule)— >
i structure us not intended or offered for sale (Sections �Ia �,a �'2 i
7044 Business and Professions Code) y
CONSTRUCTION LLNDING AGENCY
I hereby,affirm that there is a construction lending agency - 2 -1- 31 0 0
for the performance of the work for which this permit is PERMIT FEE i (Sub Total)
issued (Sec 3097 Civ C) r • ' 31 0 0 6
Lender's Name PLAN CHECKING FEE s (One Fourth Permit Fee) '
Lender s Addresss o a,0 3—8
PERMIT ISSUING FEE ,
I certify that I have read thus application and state that the TOTAL FEE—
above information is correct I agree to comply with all County _ LA 1. i
ordinances and State laws regulating Electrical wiring, and
�.�
hereby authonre representatives of this County to enter upon l
the above entioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
�Stgnature of Per [tee Date