HomeMy Public PortalAbout4933 PERSIMMON AVE_Electrical__ �• r .+f• 0�,V1 RKERS'COMPENSATION DECLARATION CE-8o6G ic/st APPLICATION FOR ELECTRICAL PERMIT
�i hereby dffirm that I have a certificate of consent to self insure,
or a ceKlficate of Workers' Compensation Insurance, or a certifiedCOUNNTYr OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3600,Lab.C.)'
04 ra
POlidy No. • Company I 1 11 FOR APPLICANT 10 FILL IN JOB
❑ N2y i IO /t
Certified copy is hereby furnished. I EACH NO. FEE ADDRESS :/ I11 Aew Residential Bldgs.&Pools 7
❑ 1 &2-Family,S Ft.. $ — $ LOCALITY
Certified copy is filed with the county building inspection y q
department. Multi-family Sq.Ft. — NEAREST
ti. CROSS ST.
D Appt. �� " i Residential Swimming Pools. OWNER OR
FIRM NAME p+II 5 O
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light�Sw. MAIL
COMPENSATION INSURANCE ADDRESS I
(This section need not be completed if the work involved by the 22,✓ First 20 `
permit Is for one hundred dollars(%lob)orless.) Total No.Z— Additional CITY G• Tel.No. 2
I certify that in the performance of the work for which this permit PLAN APPLICANT CHECK
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
�Q Total No. Additional CITY el.No.
Date Applicant �!/51 I
NOTICE TO APPLICANT: if, after making this Certificate Of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range, Heater D.W. _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU _ W.H. _ CITY Tel..No.
LICENSED CONTRACTORS DECLARATION Hood.T_ Fan _ Other_
I hereby affirm that 1 am licensed under provisions of Chapter 9 Disp. —I— Room Air Cond: CENSE O.R Class.
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER
Professions Code,and my license.is in full force and effect. DISTRICT NO. PROCESSY
Power Apparatus&Large Appliances
Size&Type HP,KW,KVA,or KVAR
License Number Lic.Class Up to 1.Incl. FINAL I
Over 1 to 10 Incl. DATE ! b
Contractor Date. Over 10 to 50 Incl. ! VALI A N 0
❑ I am exempt under Sec. Over 50 to 100 Inc.
BY A� 8
B.&P.C.for this reason
Over 100 OW.
//,PO
vices,Swbd.,MCC&PanelboardgN
Date: -200 Amp.Under 600 V Z
r_a
Signature. 201 - 1000 Amp.Under 600 V
❑
Exemption for Reg..Mairit.Elect. Over 1000 Amp,or Over 600 V
SINGLE FAMILY Temp.Power Pole&Appurtenances c 8 9 a 8 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License LawAdditional Sign Branch Circuits # 0 0 0 0 0 2
for the following reason(Section 7031.5,Business and Professions
Cod ): I o 5&50
' I,as.owner of the property,will do the work and the Misc.Conduits&Conductorsstructure '0 n o 5 8,5 o cz.�
is not.intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ ,
and Professions Code).
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there'id a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name /'
PERMIT ISSUING FEE C
Lender's Address ;
I certify that I have read this application and state.that the above TOTAL FEE
information is correct.I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
representatives of this COun to enter upon the above-mentioned
proper"r inspection pur s. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sin re o rmit ee Date