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Home My Public Portal About5539 PARMERTON AVE_Electrical_5/30/1992_outlets WORKERSCOMPENSATION DECLARATION 76A663DPW 9,68 APPLICATION FOR ELECTRICAL PERMIT I flerdbV all.". that I have a certificate of consent to self Insure T8ABfi3 or a certificate of Worker 6 Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 3600 Lab C) ' Pal"Na Company FOR APPLICANT TO RLL IN JOB 41 n ADDRESS Cenified copy is hereby furnished Nen Reetdentull Bldgs 8 Pools EACH - NO FEE ❑ dCertifieddepartment copy w filed with Re county building mepeUion 1 ul Family SFt E — $ LOCALITY ,Q department Multi lamely S0 Ft Ft — NEAREST CROSS ST Date Applicant Residenval Swimming Poole ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec _L SOWNER OR d COMPENSATION INSURANCE Light_ w FIRM NAME (This section need,not be completed if the work Involved by the Fust 20 _ "Lpermit is for one hundred dollen($100)or less) Total No Adtldional ADDRESS (/ I e I certify that in the performance of the work,for which this permit CITY • 1 Tel is issued I shall not employ any person In any manner so as to II becomelsublect to the Workers Compensation Laws Lighting Fixtures First 20 PLANCHECK Total No Additional ADDRESS Date Applicant 15 OR 20A 12DV BRANCH CIRCUITS NOTICE TO APPLICANT If after making this Certificate of CITY Tie No Exemption you should become subject to the Workers Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code you must forthwith comply with such - 11 T0401NCLUSA/E EACH _ _ - PERMIT - APPLICANT provisions or this permit shell be deemed revoked 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS - } I hereby affirm that I em licensed under provisions of Chapter 9 15 OR 20A 206V TO 277V LIGHTING EACH (L (commencing with Section 7000) of Division 3 of the Business and _ __ _ CITY Tel No 0 Professions Code and my license is in full force and effect RESIDENTIAL APPLIANCES UP TO 3HP uCENSE OR _Power Apparatus 8 Large Appluirues _ REO NUMBER Gees License Number LAC Class Size 8 Type HP KW KVA or KVAR DISTRICT NO _ P SSED BY - UP m 31nc1 ej 0! W Over 3 to 10 Incl FINAL d Contractor Date - DATE - CO ❑ Over 10 to 50 Incl p I em exempt under Sec i Over SO to 1001nc1 e2_6-1 Z VALIDATION ? B 8P C for this reason Over 100 BY�' /A - Services Swbd MCC 8 Panelboards- N H. •_' Date 0 200 Amp Under 600 V _ Signature - 201 1000 Amp Um1ar 600 V ❑ U Over 1000 Amp or Over 600 V �.�-i Exemption for Reg MElect aint IM SINGLE FAMILY Tem Power Pole 8 _ I I I�' S P Appurtenances 1� HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit TOTAL '?3 I hereby affirm that I em exempt from the Contractors License Lew for the following reason (Section 7031 5 Business and Professions Addmonal Sign Branch Circuits .. `Ja 171 Code> MCK - rirl I as owner of the property will do the work and the structure Mqc CHANGE Conduits d Conductors is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) and Professions Code) I _ - -- - , now-o a 1 /'2h dry CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for theryt}ltl:5'- perlormance of the work for which this permit is issued(Sec 3097 PERMIT FEE - - (Sub-Total) - (' Cit C) / PLAN CHECKING FEE Lender s Name nn�[ PERMIT ISSUING FEE - Lender sAddress TOTAL FEE I certify that I have read this applic on and stele that the above Information is correct I agree to c ply with all County ordinances and Slate laws ulatmg Electr alrwinng and hereby authorize representatl 0 my enter upon the above mentioned - property f in a ion p r e /0* /��JJ��jj��1� SEE REVERSE FOR EXPLANATORY LANGUAGE SIONATUR FAP ON A315W OA9rE _ `