HomeMy Public PortalAbout5514 PARMERTON AVE_Electrical__ WORKERS COMPENSATION DECLARATION 76A663 i0/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self � �
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insure or o certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) C 1 �// /'
POT No Company FOR APPLICANT TO FILL IN _'GB
❑ ADDRESS �! /l/• 77 G���
Certified copy ,s hereby furnished New Residential Bldgs 8 Pools EACH NO FEF
❑ Certified copy ,s filed with the county budding ,nspec 18 2 Family Scl Ft $ — $ LOCALITY PL,& 7-S/
tion department Multi-family Sq Ft — NE5AREST
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Date Applicant pS �n
Residential Swimming Pools OWNER OR lI G�YES
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_LightSw= MAIL
COMPENSATION INSURANCE � ADDRESS
(This section need not be completed if the woik Involved by First 20
Ar—
the permit Is for one hundred dollars ($100)or leu ) Total No Additional CITY Tel No
I certifythat ,n the PIAN CHECK
performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS '
,�j� //� Total No Additional
�Dcle L : 142 ltcont k? R £"�}i Al'oS CITY T Tel No 1
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NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over I HP PERMIT
Exemption you should become subject to the Workers Range— Heater—DW APPLICANT / R j.�r_ Ee,1!<(+ //rJL
Compensation provisions of the Labor Code you must forth Oven _ Dryer _ W M — , ADDRESS 2$ 7 C C, jRD perzil
,�,
with comply w,th'such provisions or this permit shall be Top _ FAU —W H —
deemed revoked I i Hood _ Fan _Other_ CITY Tel No V 17/j CI
LICENSED CONTRACTORS DECLARATION t LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 D,sp _ Room Air Cond REG NUMBER 1 f Q/ Class d__f 7
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO-.5,
PR SED BY
and Professions Code and my license,s in full force and effect 6
_ Size 8 Type HP KW KVA or KVAR r
C�l
icense Number—J2/ �3 2'- Lic Class e' U V
��pp Up to 1 Incl FINAL
ontrocto,T-"tiny b � ,Fj e6 t6 >— 3O Over 1 to 10 Incl DATE / r 3��.� VALIDATION F
ElOver 50 to 100 Inc BY Over 10 to 50 Incl FINAL
am exempt under Sac . rz' W
B 8P C for this reason Over 100 We
Services Swbd MCC 6 Paoelboards , Z
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
❑ Exemption for Reg Mainl Elect Over 1000 Amp or Over 600 V
SINGLE FAMILY Temp Power Pole IT. Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One
ne na Branch
Circuit'
1 hereby affirm that I am exempt from the Contractor s License Addition8 5 4 4 A
Law for the following reason (Section 7031 5 Business and, nch Circuits t
Professions Code)
❑ \ ole • • • 2
I as owner of the property will do the work and the Mist Conduits 8 Conductors
structure ,s not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 2 • • 2 5 50
7044 Business and Professions Code) 2 5 5 0 3
CONSTRUCTION LENDING AGENCY s e s
I hereby affirm that there is a construction lending agency for 0 1.3 0—84
the performance of the work for which this permit ,s issued PERMIT FEE (Sub-Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
Lender s Address
1 certify that I have read this application and state that the TOTAL FEE zS' -
above mformation is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the,abo//e-mentioned property for inspection purposes r SEE REVERSE FOR EXPLANATORY LANGUAGE
/,gnature of Permittee Date