HomeMy Public PortalAbout5904 PRIMROSE AVE_Electrical__ I '
WORKERS'COMPENSATION DECLARATION V CE 806G 10/81 APPLICATION FOR ELECTRICAL PERMIT
hereby aff that I have a certificate df consent to self.insure.,
Il. ..
or a ceQf(cate of'Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES I BUILDING•AND SAFETY
copy thereof(Sec.3800,LaS.C.) i
Policy No. .Company I FOR APPLICANT TO FILL IN JOB
❑ / �/P�
Certified copy is hereby furnished. I New Residential.Bldgs.&Pools EACH , NO. ADDRESS FEE �
Certified copy Is filed with the county building inspection 1.&2-Family,Sq.Ft.
$ — $ I LOCALITY
department. i Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant 4 Residential Swimming Pools OWNER OR
;! FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' I MAIL �/���
Outlets:R;e fight_Sw.—
COMPENSATION INSURANCE ADDRESS'���.� �//�lj��(This section need'not be completed if the work Involved by the First 20
Total Additional CITY �� Tel:No. �f� j�
permit is for one hunr(red..dollars.($100)or less.) {' t . PLAN CHE=CK
f certify that in the performance of the work. for which this permit APPLICANT
is issued, I shall not employ any person in any manner so as to i
become subject to the Workers'Compensation Laws. �' Lighting Fixtures First 20 ADDRESS
i v Additional
Date .v 7 Applicant/ ='/yJ Total No. CITY Tel.No.
NOTICE TO APPLICANT: If,. after making this .Certificate of i. Fixed Appliances Not Over 1 HP
Exemption,you should become subject to the Workers'Compensation Range_ HeaterD.W. _
APPLICA
NT � d67'
provisions of the Labor.Code,you must forthwith comply with such r Oven _ Dryer— W.M._ ADDRESSAl
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _
CITY ZG Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I• �j _'g Z34
I hereby affirm.that I am licensed under provisions of Chapter 9LICENSE OR
(commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. �' REG.NUMBER Class.
Professions Code,and my license is in full force and effect. I DISTRICT NO. PROC Y
Power Apparatus&Large Appliances h
Size&Type HP,KW,KVA,or KVAR V Q
License Number Lic..Class Up to 1 Incl: F!NAL
Over 1 to 10.Incl. DATE ( ��
Contractor Date I / J VA ATION
Over 10 to 50 Incl. FINA
0 1 am exempt under Sec. Over 50 to'100 Inc. BN
B.&P:C.for this reason Over 100 ILIN
Services,Swbd.,MCC&Panelboards I!
Date: 0-200 Amp.Under 800 V
- I
Signature I 201 - 1000 Amp.Under 600 V i
Over 1000 Amp.or Over 600 v + 6 8 2 A
Exemption for Reg.Maint.Elect.
SINGLE FAMILY ? Temp.Power Pole&Appurtenances I # 0,0 0 0 0 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law 1. o 0 1 2 0 0
Additional Sign Branch Circuits
for the following reason.(Section 7031.5,Business and Professions �+
Code):
o 0.12005
I,as.owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 704.4, Business � Other(See Complete Fee Schedule) _ , Q, 987
and Professions Code). 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, r PERMIT FEE (Sub Total)
Civ.C:). i
I PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above I TOTAL FEE• I.
information is correct.I agree to comply with all County ordinances ,
and State laws regulating Electrical wiring, and hereby authorize i
representatives of this County to enter upon the above-mentioned l
property for inspection purposes. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
x-17 i
Signaturg-of Permittee Date 1 _
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