HomeMy Public PortalAbout6023 PRIMROSE AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION i"
C5-8C6G (2-BO) APPLICATION FOR ELECTRICAL PERMIT
N � E$O6 �
I hereby affirm thai I' have a certificate of consentto self COUNTY OF LOS'ANGELES BUILDING AND SAFETY
insure,or a certi icate ofWorkers'Compensation Insurance,or s
a certified copy t reof(Sec.3800,Lab.C.) �7 /�Q AA n
FOR APPLICANT TO FILL IN JOBADDRESS !/'�� / /'0 tel/�-OSE
Policy No. Company EACH NO. FEE
New Residential Bldgs.&Pools
Certified.co0y is he eby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY'
Multi-family Sq. Ft. — NEAREST 2v�T
Certified copy is filed ith the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR
Date .Applicant FIRM NAME
Outlets: Rec. Light Sw. , 'ADDRESS 6,02-3
1, First 20
CERTIFICATE O EXEM TION FROM WORKERS' '/Li
' COMPEN ATIO.. INSURANCE Total No. Additional CITY el No. T7 7
PLAN CHECK IL
(This section need not. be completed if the work involved APPLICANT p
by the permit is for one undred dollars ($100) or less.) Lighting Fixtures -First.20 ADDRESS U -
Total No. Additional
I certify that in the performs a of the work for which this CITY Tel No. a s�Y7e O
Fixed Appliances Not Over 1 HP
permit is'issued, I"shall not amp y any person in any manner f! PERMIT ()
so as to become subject to the kers'Compensation L s. l Range_Heater D.W._ APPLICANT ( L-�/�. J/V W
Date /4
` Oven% _ Dryer_W.M._ ADDRESS �� �' W
`Y w,t p _FAU _.W.H.._
Date A licant CITY , GJ C�, Tel No:
od _ Fan —Other_
NOTICE TO APPLICANT: If, after m ing this Certifica. f isp. Room Air Cond.— LICENSE OR
Exemption, you should .become sub ct to the Wo r ers' REG.NUMBER Class
Compensation provisions of the Labor Code,you must forth- I' Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or his permit shall be
deemed revoked. Size&Type WP,KW,KVA,.or,KVAR
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE
LICENSED CONT CTOR$DECLARATION ,� V�4LIDATION
Over 10 to 50 Incl.
I hereby affirm that I am lic sed under provisions of Chapter I: Over 50'to 900 Inc. FINAL
9 (commencing with Section 00)of Division 3 of the pt
Over 100 BY �>
ness and Professions.Code,and y license is in full force and
effect. I Services � /g' p?Wd:
i 0-200 AW�lln, /600 V
License Number a��/S� Li Class C'.�D 201-1000 Amp.Under 600 V
Contractor Zauc46s Ems• Date. 3� i; Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DE 'I.ARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt fro the Contractor's (1 Sign with One Branch Circuit : 1 5 6 7A
License Law for the following reason .(Section 7031.5, Busi- Additional Sign Branch Circuits ' 0 0 0 0 0
ness and Professions Code):
I, Misc.Conduits&Conductors ° C 3 6 J 0
%I as owner of the property, will do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for We (Section n r o .G G
7044,Business and Professions Code).
CONSTRUCTION LENDING AQENCY �0 14. Q_f v
I hereby affirm that there is a construction lending agency
for the performance of.the work for which this permit is -Total)
PERMIT FEE
(Sub
issued(Sec.3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One=Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
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
?ZvRe-mUentiod pro erty for' s ction purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date