HomeMy Public PortalAbout5730 RIO HONDO AVE_Electrical__ woRKE.W'COMPENSATION,DECLARATION 78-863 10/81 APPLICATION FOR ELECTRICAL PERMIT
I_*rbbX,W#tsm thplt I have a certificate of consent to self insure, CE-BoeG
c.to?•a ceirtifigate of Workers'Compensation Insurance, % a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
6i7w thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ ADDRESS 7 n O
Certified copy is hereby furnished. New Residential Bldgs.&Pop Is EACH NO. FEE
1 &2-Family,Sq.Ft. L g'O 6446
$ — $ LOCALITY A a
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. 'CROSS Sl
Date Applicant
Residential Swimming Pools OWNER OR + '
CERTIFICATE OF EXEMPTION FROM WORKERS' � . )n FIRM NAME /
Outlets:Rec Light Sw.� M'°dL
COMPENSATION INSURANCE ADDRESS S ® d
bu
(This section need not be completed If the work Involved by the -�/ First 20
Total No. Additional CITY L� Tel.No
permit:is for one hundred dollars($100)or less.) ,
I certify that in the performance of the work for which this permit$ nLAN PucnNT K e, !
is issued, I shall not employ any person in any manner so as to
become subject to,the Workers'Compensat' : Laws. Lighting Fixtures First 20 ADDRESS 573 . 2 t�W
Additional _
y p Total No. CIT Tel.No.
Date 5-�/'–o Applicant – f / Tr – S
NOTICE TO APPLICANT: If, after m in th' Certif cats of Fixed Appliances Not Over 1 HP PERMIT -74
Exemption,you should become subj to the Workers'Compensation Range_ Heater D.W. _ APPLICANT C
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS 7 ��
provisions or this,permit shall be deemed revoked. Top _ FAU _ W.H.
CITY . - / Tel.No�r,--
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ j–
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR ._—
(commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances � U(XJ
DISTRICT'NO,,,r� 'r�/ PROCE Y
•
Size&Type HP,KW,KVA,or KVAR O
License Number Lic.Class Up to 1 Incl. FINAL � 8
Contractor Date Over 1 to 10 Incl. DATE Z17 ��(y� f VA -TION 0
Over 10 to 50 Incl. CC// (O�,
FINAL
'0 I am exempt under Sec.. Over 50 to 100 Inc. gy
W
BAP.C.for this reason r Over 100 N
Services,Swbd.;MCC&Panelboards - Z
Date 6,. 0-200 Amp.Under 600 V
Signature r 201 - 1000 Amp.Under 600 V
E] �, Over 1000.Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY ;a. Temp.Power Pole&Appurtenances .
HOME OWNER-BUILDER DECLARATION t Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031,5,Business and Professions Additional Sign.Branch Circuits :271 Q 3 A
Code): # o.0 0 0 0 2
2 I,as owner of the property,will do,the.work and the structure Misc.-Conduits&Conductors
is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ $ I o o 5 2 0 0
and Professions Code). i , o 0 0 5 2 0 0 5
CONSTRUCTION LENDING AGENCY 0 5 2 6 g 7
1 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)
Civ.C.).
PLAN CHECKING FEE
Lender's Name
' PERMIT ISSUING FEE .
Lender's Address t s®
I certify that I have read this application and state that the above. TOTAL FEE.
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 i ection purposes. i
SEE REVERSE FOR EXPLANATORY LANGUAGE
S-,
SIgr1a);MerrNtteLa Date
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