HomeMy Public PortalAbout5741 PRIMROSE AVE_Electrical__ • 11
WORKERS'.COMPENSATIONDECLARATION 20.00lADPW s/e7 APPLICATION FOR EL ..CTRICAL PERMIT O
ibnbe3
hereby"affirm that I have.p cprtificQte of consent to self cE�e06G
nsure, od�a certifjcate of Workers'C pensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Ir a certified copy thereof(Sec. 3800, Lab. C.)
olicy No. Company FOR APPLICANT TO FILL IN .JOB -
Certified copy.is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
Certified no is filed with the count building $ — $ LOCALITY
� copy� y : g inspec- 1 8 2-Family, Sq. Ft.
tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CR
ate Applicant OWNER
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
First 20 �`�
'his section need not be completed if the work involved by Total No. Additional CI Tel. N
ie permit Is for one hundred dollars($100)or less.) I
1 PLAN CHECK certify that in the performance of the wank for which this r • APPLICANT
srmit is issued,•I shall not employ any person in any manner l `
t as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ` ADDRESS
Additional
rte Applicant
Total No. j CITY 'fel. No.
Fixed Appliances Not Over 1 HP PERMIT
DTICE TO APPLICANT:_If; after making this Certificate of APPLICATION
'emption, you should become subject to the Workers' Range— Heater—D.W. —
rmpensation provisions of.the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
th comply with such provisions or this permit shall be Top FAU —W.H. —
lemed revoked. CITY Tel. No.
Hood — Fan —Other—
LICENSEDCONTRACTORS DECLARATION LICENSE OR
1 Disp. — Room Air Cond. — Class.
ereby affirm that I am licensed under provisions of Chapter 9 REG.NUMBER
l immencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT5.. PSSED d
cl Professions Code,and my license is in full force and effect.
Size&Type HP,'KW., KVA, or KVAR 199 Y_ U
erase Number. Lic. Class- Up to 1 Incl. FINAL A Ir
Over 1 to 10 Incl. I DATE ✓ VALIDATION cc
' ntractor, Date Over 10 to 50 Incl. 0
FFIYNTkLI am exempt underSec. Over 50 to 100 Inc. LU
B.&P.C. for this reason Over 100 d
Date:
Services, Swbd., MCC&Panelboards ® Z
- Z
0-200 Amp. Under'600 V
Signature 201 - 1000 Amp. Under 600 V
Exemption for Reg. Maint. Elect: Over 1000 Amp. or Over 600 V
SINGLE FAMILY I3 7 i
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances LrO 7
;reby affirm that I am exempt from the Contractor's License
Sign with One Branch Circuit j ITEMS
' for.the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Fi,sas
Mist. Conduits&Conductors
ions Code): I TOTAL 31.00
I { 7
owner of the property, will do the work and the {� CHECK z1d00
t structure isnot intended or offered'for sale(Section 7044, her(S a orimplete he le.)-
CHANGE 1® ).�
Business and Professions Code).
.013
CONSTRUCTION LENDING AGENCY.
reby affirm that there is'a construction lending agency for I
jperformance of the work for which this permit is issued PERMIT FEE (Sub-Total) 0000-0001 2/ 6 )FLA,
r '
i. 3097, Civ. C.). 8805 1 AM 1 f 38
1
PLAN CHECKING FEE i
er's Name
PERMIT ISSUING FEE 13 ,
ier s Address
'rtify that I have read this application and state that the TOTAL FEE r,
,,e information is correct. I agree to comply with all County ,
nances and State laws regulating Electrical wiring, and
,Iby authorize representatives of this County to enter upon t:
bove- ention d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r�� �4—!& 1
iature of Permittee Date �' i 1• ®s