HomeMy Public PortalAbout5432 PARMERTON AVE_Electrical__ WORKERS COMPENSATION DECLARATION 7E8D6 10,91 (APPLICATION FOR ELECTRICAL PERMIT
I herebyaffirm that I have a certificate of consent to self CE BSG �-y--
insure r a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES / r BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )� ( [
Pal i'cy No Company J ) I FOR APPLICANT TO FILL IN '08ADDRESS
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE E
❑ Certified copy is filed with the-county building inspec- 1 8 2 Family Sq)Ft $ — f LOCALITY
tion department s Multi-family'Sq�Ft — NEAREST 'DI3 it r4
Residential Swimming Pools CROSS ST
Date Applicant , OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS` Outlets RecLightSw_ MAIL C`
section COMPENSATION INSURANCE First 20 ADDRESS J
(This need not be completed d the'vrork Involved by Total No Additional CIN Tel No - �'
the permit is for one hundred dollars ($100) or less )
I certify that in the performance of the work for which this PVT CK
PLAN
CHECK
permit is issued I shall not employ any person in any manner
ANT
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS '
>9Total No Additional Date�Applicont' CITY - Tel No
NOTI TO PLICANT If after making this Certificate of Fizad Appliances Not Over I HP PERMIT
Exemption you should become subject to the Workers Range_ Heater_D W — APPLICANT
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 —W H —
deemed revoked Hood _ Fan —Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that lam licensed under prov'sans of Chapter 9 Disp Room Air Cond — REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances CE
DISTRICT NO PROSS BY }
and Professions Code and my license is in full force and effect
Size 8 Type HP KW KVA or KVAR `�j y O
License Number LUc Class _ V
Up to 1 Incl FINAL 7
Over 1 to 10 Incl DATE VALIDATION O
Contractor Data Over 10 to 50 Incl
F-1 FINAL
I am exempt under Sec Over 50 to 100 Inc BY
B 8P C for this reason Over 100 N
Services Swed MCC 8 Ponelboards , - _
Date 0 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V _
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maine Elect ;2 2 3 B 8 A
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit # e e s's f s2
1 hereby affirm that I am exempt from the Contractor s License, Or
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits - 2 • • 2 5 5 0
Professions Code) - 1. - I '
❑ I as owner of the property will do the work and the Misc Conduits 8 Conductors - • • e 2 5'5 0 v r
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 0 62 9_8 4
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby 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
Lender s Name D
PERMIT ISSUING FEE
Lender s Address �
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 jaws regulating Electrical wiring and
hereby authorize representatives of thu County to enter upon
the"e-mentioned proper for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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ignoture of Permittee pate