HomeMy Public PortalAbout5933 1/2 PRIMROSE AVE_Electrical__ W�.KERS'COM'PENS'ATION DECLARATION IICEA806G (2 80) APPLICATIOIVl"FOR IELECTRICAI PERMIT J
I hereby affirm that I have a certificate of consent to self -COUNTY OF LOS ANGELES BUILDING AND SAFE7T7
insure,or a certificate of Workers'Compensation Insurance,or ' f
a certified copy thereof(Sec.3800,Lab.C.) _":� "fl
FOR APPLICANT TO FILL IN JOB
Policy No. 0 Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 5931&5931h Primrose
Certified copy is hereby furnished. 1 &2-Family,Sq..Ft. $ — $ LOCALITY Tem le Cit
❑ N
Ft.
Certified copy is filed with the county building inspection Multi-family Sq. CROSSEAREST ST Las -Tunas
'department. Residential Swimming Pools OWNER OR
' FIRM NAME-Mushinskie
Date Applicant I Outlets: Rec QLightl2_Sw.14_
First 20 11521 ADDRESS5937 Primrose
-
CERTIFICATE OF EXE..MPTION FROM WORKERS' Total No. 56
COMPENSATION INSURANCE Additional AIPCITY Temie City. Tel No. 287_2256
PLAN CHECK o-
(This section need not be completed if the work involved PPLICANT V
Li htih Fixtures , First 20
by the permit is for one hundred'dolhus ($100) or less.) l g g ADDRESS
I Total No.�_ Additional
I certify that in the performance of the work for which this CITY Tel No.
permit,is issued, I shall not employ Fixed'Appliances Not Over 1 HP
P p. Y an Y person in any manner � PERMIT U
so as to become subject.to the kers'Compensation Layn Range_Heater D.W. _ APPLICANT .eonlee & Son Eleetriv OW.
A. E;�L Oven _ Dryer_W.M.._ ADDRESS2650 Np San 23 Gabriel' Blvdu3
Date 4 oZpplicant Top _ FAU- W.H:,_
Hood — Fan Other_ / CITYR' mead • Tel No.280-2007
NOTICE TO APPLICANT: If,after making this-Certificate of Disp. 2_ Room Air Cond— + ` ICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER 242432 _Class _C, 1
Compensation provisions of the Labor Code,you must forth- 'Power Apparatus&Large Appliances DISTRICT NO PR ES BY
with comply with such provisions or this permit shall be
deemed revoked. 1.1 Size&Type HP,KW,KVA,or KVAR fy�
Up.to 1 Incl. CC//
FINAL
LICENSED CONTRACTORS DECLARATION "!' Over 1 to.10 Incl. DATE 7 VALI DATIO
Over 10 to 50 Incl.
I•hereby affirm that I am licensed under provisions of Chapter Over 50 to 1.00.Inc. ' FINAL
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY /
ness and Professions.Code,and my license is in full force and K
effect. Services
License Number24 24 3 2 C10 0-200 Amp.Under 600 V
Lic.Class
' 201-1000 Amp.Under 600 V
ContractoC nlee Son Date 423/82 Over 1000 Amp.or Over 600 V
ec ri :I
HOME OWNER-BUILDER DECLARATION ,Temp.Power Pole&Appurtenances
I hereby affirm. that I am exempt from the Contractor's Sign with One Branch Circuit. r 3 7 5
License Law for the followirig reason (Section 7031.5, Busi- Additional Sign Branch Circuits 1•,
ness and Professions Code): ��' o-0- 0 0 0
Misc.Conduits&•Conductors•
❑ I, as owner of the property, will do'the work and the Other(See Complete Fee Schedule)— 2 0 0 [�
structure is not intended or offered for sale (Section
'7044,Business and Professions Code). - 0,0 'o [( r,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Q _�7
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
,issued(Sec.3097,Civ.C.).
'Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
j
!Lender's Address PERMIT ISSUING-FEE
'I certify that I have read this application and state that the TOTAL FEE
11above 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
t ve-mentioned property fo spection pur*,7j
s. SEE'REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date