HomeMy Public PortalAbout5948 RENO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION iMe�DPW t,2.9,) APPLICATION FOR ELECTRICAL PERMIT LJ
hereby affirm•:that I.,have a certificate of consent to.self:insure.,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
POIic No. /"I Q_7 9 S 3ompanyS*�—a dSt ete FOR APPLICANT TO FILL IN 'AR
u Q A
ADDRESS ` G V16
Cer.tified•oopy is hereby furnished. New Residential'Bldgs.&Pols NO. EACH FEE
❑ $ $ ✓ LOCALITY
Certified copy is filed with the county building Inspection 1&2-Family,Sq.Ft. NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR r o
MAP BOOK �D L PAGE O/71PARCEL 49'Y99-
CERTIFICATE
99-CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR
COMPENSATION INSURANCE First 20 FIRM NAME /C /NQ�V(This section need not be completed the.work.Involved by the MAIL
Total No. Additional ADDRESS �p U 3G Z
permit Is for one hundred dollars($7000)or less.) -
I certify that in the performance of the work for which this permit CITY ` Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN.CHECK
become subject to the Workers'Comp ation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER'3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT e.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)-of Division 3.of the Business-and CITY Tel.No.
Professions.Code,and my license is in full force and effect. Over 10 to 50 Incl. `
LICENSE OR- n / Claw. !v a
('� �7f[n� /J Over 50 to 100.Incl. REG.NUMBER W 6
License Number r^`�( • Lic.Classes Over 400 DISTRICT NO. PRI ED ED BY 0
Services,Swbd.,MCC&Panelboards
J • c�Cril...d `v
Contractor Tit- «N&02M1Vate 21-16-9,A 0-399 Amp.Under 600 V FATE 0
❑ I am exempt under Sec. 40.0-10 00 Amp.Under 600 V VALIDATION 0
Over 1000 Amp.or Over 600 V FINAL .' W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY �( CD
Date: 15A,or 20A,120V,Lighting or Recept: VJ) z
1 To 10 Branch Circuits e
Signature 11 To 40 Branch Circuits
❑ 41 Or More'Branch Circuits 2
EXemptidn for Reg.Maint,Elect. 15A,20A,208V To 277V Lighting Br.Circuits
JL
SINGLE FAMILY Temp.Power Pole&Appurtenances ACTaa
HOME OWNER-BUILDER DECLARATION3 ,3'28.60
1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 3e03
for.the following reason (Section 7031:5, Business and Professions Additional Sign Branch Circuits 1 ITEMS
Code): _
❑. 1,as owner of the property,will do the work and the structure Misc.'Conduits&.Conductors TOTAL +�' ® '�
is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) CHECK 328.60
and Professions Code). , -
CHANGE .CIO
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) :100 1,51 0000-0001 7/16/96
Civ.C.)
PLAN CHECKING FEE 7468 1 ASI 8:07
Lender's Name
PERMIT ISSUING FEE p� d
Lender's Address
I certify that I have read this application and under penalty of pur)ury state TOTAL FEE
that the 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 property
for inspection purposes... /f� SEE REVERSE FOR EXPLANATORY LANGUAGE
9�E ERMInEE ?4Sriv Z—Z&DATEO,-6