HomeMy Public PortalAbout5921 RENO AVE_Electrical__ I
WORKERS'COMPENSATION DECLARATION 78-883 10/e1 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consaetl,to,sel ��insure, I CE-BOBG
or a certificate of Workers' Compensation Insurance, or a certified i COUNTY OF LOS ANGELES BULDING AND SAFETY
copy thereob Sp8rb.C.)
Pollcy�l� 5 Company FOR APPLICANT TO FILL IN JOB. /
❑ Certified copy Is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS ` d
1 & 2-Family,Sq.Ft. $ — $ LOCALITY
- G
Certified copy is filed with the county building inspection — NEAREST
department. Multi-familySq.Ft.
Date �' Applicant ��°' Residential CROSS ST.
Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec
—Light—Sw. MAIL
—:
COMPENSATION INSURANCE ADDRESS .y
(This section need not be completed If the work Involved by the First 20
permit is for one hundred dollars($900)or less.)
Total No. Additional CITY Tel.No.
I certify that in the performance of the work for which this permit 1 APPLICANT K
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
Additional.
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE M APPLICANT: If, after making this Certificate of '/ i
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT ��y l�i�//
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESSO eoZ—
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H.
CITY el.N
LICENSED CONTRACTORS DECLARATION Hood - Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9Disp. - Room Air Cond. LICENSE OR Class,
(commencing with Section 7000)of Division 3 of the Business and R.EG:NUMBER �i
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. o SSED BY
r— � �J7� Size&Type HP,KW,KVA,or KVAR /+ �� Q
License Number ! Lic.Class Up to 1 Incl. FINAL
`�,/ l� Over 1 to 10 Incl. DAA �� VALIDATION Q
Contractor (�_ /_�_Date 'b Over 10 to 50 Incl.
FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY 01 d
B.&P..C.for this reason Over 100 N
Services,Swbd.,MCC&Panelbo ?�f
Date: 0-200 Amp.Under 600 o6a
Signature 201 - 1000Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from-the Contractor's License Law ,v
Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions 65°60
Code):
El 1,
Conduits&Conductors 1 ITEMS i,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) _
is not intended or offered for sale (Section 7044, Business ® TOTAL 65.61D
and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK 65.60
1 hereby affirm that there is a construction lending agency for the CHANGE Go.
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total)
Civ.C.).
Lender's Name
PLAN CHECKING FEE DOM-0001 10/31/95
PERMIT ISSUING FEE d Q 3M3 I pM110-24
Lender's Address
I certify that I ave read this application and state that the above TOTAL FEE .
information' rrect.I agree to comply with all County ordinances
and Stat s regu ' Ele ical wiring, and hereby authorize
repress s of I o nt enter upon the above-mentioned
proper for insp o pu p s. SEE REVERSE FOR EXPLANATORY LANGUAGE
igna ure of Pe ' Date