HomeMy Public PortalAbout5325 PERSIMMON AVE_Electrical__ WORKERS'COMPENSATION DECLARATION ' to/eI APPLICATIO,N FOR ;ELECTRICAL PERMIT
I,hero.liyfCE-8Maffirm that I have a certificate of consent to self CE-BObG
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. �]OB
Company FOR APPLICANT TO FILL IN .riJ a
5- �Ljrr��
❑ Certified copy is hereby furnished. New e7
Residential Bldgs. &Pools EACH NO. FEE ADDRESS z- � y ®.�✓
�
❑ $ — $ LOCALITY
Certified copy is filed with the.county building inspec- 1 8 2-Family, Sq. Ft. i � C -
tion department. Multi-family Sq. Ft. — ;NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools ��. , OWNEROR ��yy
t�t FIRM NAME a�7• .N Gr•�!C
CERTIFICATE OF EXEMPTION FROM WORKERS' MgIL
COMPENSATION INSURANCE Outlets: Rec Light Sw._ DDRESS 32-0
i (This section need not be completed if the work involved by First 20
the permit Is for one hundred dollars($100)or less.)-
Total No. Additional CITY /&t` Tel. No.Zpc,2111G"
1 certify that in the performance of the work for which this PLAN CHECK
permit is issued, I:shall not employ any person in any manner APPLICANT
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
f I Total No. Additional
Dat —f °� Applicant �= 2;re,cM e- I CITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption; you should become subject to the Workers' Range_ Heater—D.W. _ APPLICANT e3kd R
Compensation provisions of the Labor Code, you must forth- I, Oven —Dryer _W.M. ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed.revoked. ICITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood Fan _Other_
LICENSE
I hereby affirm that I am licensed underDis;provisions of Chapter 9 p' L Room Air Cond. DREG.NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Ipower Apparatus 8 Large Appliances DISTRICT NO. OC ED BY
dam.
and Professions Code,and my license is in full force and effect. I p
' Size&Type HP, KW, KVA, or KVAR
License Numbella/`r // Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 Incl.
'Contractor S- ��eC(1o��Date l IDATE VAUDATI
❑ j Over 10 to 50 Incl. FINAL W
I am exempt under Sec. {{ Over 50 to 100.Inc. l BY O:
BAP.C. for this reason i Over 100 Z
Date: Services, S oards
Amo LlndPr 600 4 �
Signature 201 - 1.000 Amp. Under 600 V '
❑ I
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances -
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and I. Additional Sign Branch Circuits
Professions Code): I
❑ I, as owner of the property, will do the work and the I Misc. Conduits&Conductors f
structure is not intended or offered for sale (Section ) Other(See Complete Fee Schedule)_ 4®
7044, Business and Professions Code). I I y5 8 5 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for ( I # 0 0 0 0 0 2
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) I
(Sec. 3097,Civ. C.). i 1 3125
PLAN CHECKING FEE o 0 0 3 1.250'
Lender's Name 1 `
Lender's Address PERMIT ISSUING FEE u ,i 1.1.0 4 8 6
I certify that I have read this application and state that the TOTAL FEE f i
above information is correct. I agree to comply-with all County
ordinances and State laws regulating Electrical wiring, and
hereby autbiorize repre ntatives of this County to enter upon I
the ove entioned r peaty f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Per Ittee Date i j