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HomeMy Public PortalAbout5815-5817 RENO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION I CE-876AG63 6G (2-80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self i COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) Policy No.34q 2 A�-)� _d FOR APPLICANT TO FILL IN NO. FEE JOB e 42 Company - i New Residential Bldgs.&Pools ADDRESS 6O�l� —/ Q Certified copy is hereby furnished. I 1 &2-Family,Sq. Ft. $ — s LOCALITY Certified copy is filed with the count Multi-family Sq. Ft. NEAREST y buildin g inspection Residential Swimming Pools CROSS ST v department. OWNER OR Date IaZZ Applicant Air-1ro,Inc, Outlets: Rec4Light Sw. MAIL �/�/ F U� Ile I First 20 ADDRESS /!oP-74 V CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITYej1 t,C Tel No. COMPENSATION INSURANCE PLAN CHECK a (This section need not be completed if the work involved APPLICANT by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS V Total No. Additional W I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0 permit is issued, I shall not employ any person in any manner PERMIT V so as to become subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT i" — Q 1f Ld W IL Oven _ Dryer_W.M._ ADDR.ESSW /� �j rn Date Applicant Top _ FAU _W.H. G �' `� F z Hood — Fan —Other CITY 9+f 1,p Tdf No.I s-317rS NOTICE TO APPLICANT: If, after making this Certificate of Disp. —Room Air Condom LICE SE OR Exemption, you should become subject to the Workers' REG.NUMBERZ 8228 Class O Compensation provisions of the Labor Code,you must forth- Power Apparatus& Large Appliances DISTRICT NO, PROCESSE BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVA,or KVAR 6^,c ©(�j Up to 1 Incl. J D ver 1 to 70 Inc[. FINALDATE LICENSED CONTRACTORS DECLARATION VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter 'Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY Z11 ness and Professions Code,and my license is in full force and effect. Services �-1 0 0-200 Amp..Under 600 V License Number r+�2 Lic.Class 201:1000 Amp.Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances f� I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit Additional Sign,Branch Circuits a License Law for the following reason (Section 7031.5, Busi- ness and Professions'Code): 0 0 0 0 0 i Misc.Conduits&Conductors I, as owner of the property, will do the work and the Other(See Complete Fee Schedul )— r a 0 4 U ? F structure is not intended or offered for sale (Section �,e� 7044,Business and Professions Code). o o n CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency a (I 2 17 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) 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 r oCS hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature o ermitt a Date