HomeMy Public PortalAbout5925 RENO AVE_Electrical__ 176A
WORKERS'COMPENSATIONDECLARATION ICE-8806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate. of consent to self COUNTY OF LOS ANGELES C BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.) /V
,{� .�d-�� ro7 ,,�y,���� FOR APPLICANT TO FILL IN JOB -15- - RIFIVO
PolicyNo��f Company�LdG'IL&,R—�� EACH NO. FEE ADDRESS // �7
IV/V/67 At New Residential Bldgs.&Pools
❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY 7Z-_r�PLE e17-P
Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. IN
Y Residential Swimming Pools
214/ AveLS L h p i ' OWNER M B
FIRM NAME 17 � uQ C:C
Date Applicant Outlets: Rec.—Light Sw. MAI L
First 20 ADDRESS Z JS.-
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY 7r-MW7Z f d/ Tel No.
COMPENSATION INSURANCE PLAN CHECK d }
APPLICANT
(This section need not be completed if the work involved O
Lighting Fixtures First 20
by the permit is for one hundred dollars ($100) or less.) Total Na. Additional ADDRESS 0
I certify that in the performance of the work for which this Fixed Appliances Not.Over 1 HP - CITY Tel No. O
permit is issued, I shall not employ any person in any manner PERMIT F'
so as to become subject to the Workers'Compensation Laws. Range_-Heater D.W. APPLICANT vez—T Lz L'cG w
Oven _ Dryer_W.M.—L ADDRESS 922-
/
Date ' Applicant Top _ FAU _W.H. Z
Hood _ Fan _Other_ CITY Lf/ Tel No.2_RPg-_jr34.
NOTICE TO APPLICANT: If, after making-this Certificate of Disp. _Room Air Cond.--L.. -3SV LICENSE%R ",,�,
Exemption, you should become. subject to the Workers' R'EG.NUMBER 7�< Z Class Q
Compensation provisions of the Labor Code, yoti must forth- I Power Apparatus&Large Appliances DISTRICT NO. PROCE§SED BY
with comply with such provisions or this permit shall be
deemed revoked. I Size&Type HP,KW,KVA,or KVAR � r�
Up to 1 Incl. I I
FINAL d
LICENSED CONTRACTORS DECLARATION
Over 1 to 10 Incl. DATE ` ' VALIDATIONOver 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 BYQ'
ness and Professions..Code, and my license.is in full force and
effect. Services
License Number Lic.Class
2,�Z�?i C: 10 0-200 Amp.Under 600 V 1 �0
•
201-1000 Amp.Under 600 V
Contractor ,kV E LS Date '��fo�X 414 Over 1000 Amp.or Over 600 V 137 '_-5 A
HOME OWNER-BUIL1. DER DECLARATION Temp.Power Pole&Appurtenances S; u o o o 2
Sign with One Branch Circuit. 1 .
I hereby affirm that I am exempt from the Contractor's c,O ; 7 C. .
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits (J
ness and Professions Code): �, r• C T
Misc.Conduits&Conductors '
❑ I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— i' f,U 6-P [i.
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is•a construction lending agency
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 Q S�
I certify that I have read this application and state that the TOTAL FEE 3�
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 above-mentioned pro rty for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date