HomeMy Public PortalAbout5915 1/4 PRIMROSE AVE_Electrical__ 4, WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I heraffirm that I have a certiCE-806G of consent To self CE-806G
at'hs r ,.d a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
sr a certified copy thereof (Sec.,3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB � /
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS. C /� r ® ST
❑ LOCALITY
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ / r i! f'
tion department. Multi-family Sq. Ft. —
NEAREST
Residential Swimming Pools CROSS ORNER T. s
Date Applicant + FIRM NAME 46--�-
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light. Sw._ MAIL
COMPENSATION INSURANCE ADDRESS //f
(This section need not be-completed If the work Involved by Total No. First 20 Additional CITY' G Tel. No..2
the permit is for one hundred dollars($1.00)or less.)
I certify that in the performance of the work for which this APPLLIICANTK
permit 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
��ff
Total Na. Additional CITY Tel. No.
Date�d "/S WApplicpnt, � A-4,4 7 Fixed Appliances Not Over 1 HP PERMIT
NOTICE, TO APPLICANT: If, after making this Certificate of APPLICANT _,
Exemption,
you should become- subject to the Workers' Range— Heater_D.W. —
Compensation provisions of the Labor Code, you must forth- Oven _Dryer —W.M.— ADDRESS lw� ��v�
with comply with such provisions or this permit shall be Top — FAU —W.H. —
Hood Fan —
deemed revoked. CITY 'J"J Tel. NqA7
— Other—
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LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER 75 Class.
el
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. /% PROCE Y
and.Professions Code,and my license is in full force.and.effect. Power Apparatus&Large Appliances, i (YJ
Size&Type HP; KW, KVA, or KVAR' Jl �/ O
License Number 7'/G ( 9!3 Lic. Class- Up to 1 Inc[. FINAL U
/� Iv /� �Date 1f�—ldf Oyer,l to 10 Incl. DATE VA D TION 0
Contractor Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec-. Over 50 to 100 Inc. BY
Over 100 yZ
B.BP:C, for this reason $ 1 2 6 A
Services, Swbd., MCC&Ponelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V # o'o o 0.02
Over 1000 Amp. or Over 600 V
❑ Exemption for Reg. Maint. Elect. i , I o'0 11.25
SINGLE FAMILY Temp. Power Pole&Appurtenances o o'0 1 1.2 5 6
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit.
I hereby affirm that I a"m exempt from the Contractor's License Additional.Sign Branch Circuits
Law for the following.reason (Section 703,1.'5, Business and g ) Q'1 5 $7
Professions Code):
❑ I, as owner of the property, will do the work and the M!sc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ►
7044, Business and Professions Code).
'CONSTRUCTION LENDING.AGENCY
I hereby.offirm that-there is a construction-lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ.. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's.Address '
I certify that I have read this..application and state that the TOTAL FEE pa
above information is correct.I,agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the ove-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature Permittee Date