HomeMy Public PortalAbout5740 RIO HONDO AVE_Electrical__ WORKERS'COMPENSATION DEdL/'RI'TI.O"1 CE 8o6G '°'a' APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent tb self insure,
or a certificate of Workers`Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C,:)
Policy No. Companyi FOR APPLICANT TO FILL IN JOB
El Certified co EACH NO. FEE ADDRESS
copy is hereby furnished_ New Residential Bldgs.&Pools
R ied co 1 &2-Family,Sq.Ft. _ $ LOCALITY
Certified
copy is filed with the county building inspection
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
'FIRM NAME Q
CERTIFICATE.OF EXEMPTION FROM WORKERS' Outlets:Rec�Light. Sw. t.
, ,COMPENSATION INSURANCE ADDRESS
(This section need not be completed If the work Involved by thel,� First 20
permit is for one hundred dollars($100)or less.)
Total No. Additional CITY Tel.No.
r I certify that in the performance of the work for which this permit APPLj CC NTCK
,1,,.Is issued, I shall not employ any person in any .manner so as to
become subject to the Workers'Compen tion Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total'.No. � .CITY Tel.No.
Dat – 3_2f Applica Appliances Not Oder 1 HP. PERMIT
NOTICE .TO APPLICANT:, If, a er making this Certificate. of Fixed. APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. ._
provisions of.the Labor Code,you.must forthwith comply with such Oven _ Dryer_ W.M.._ ADDRESS
provisions or this permit shall be deemed revoked. Top _ FAU W.H.,_ CITY Tel.No:
LICENSED.CONTRACTORS DECLARATION Hood — Fan Other_
I hereby affirm that I am;licensed under provisions of.,Chapter 9LICENSE.OR,
Disp: -Room Air Cond. Class.
(commencing with Section 7000)of Division 3 of fhe'Business and REG..NUMBER
Professions Code,:and my iioenseis'in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PR CE ED BY
Size&Type HP,KW,KVA,or KVARv Q,
License Number Lia Class Up to 1 Incl.. FINAL9 �+
Over 1 to 10 Incl. DAT _ VALIDATION
Contractor I A
Date Over 1'0 to 50 Incl.
FINA .
❑ I am exempt under Sec. X Over 50 to 100 Inc. BY
W '
BAP.C.for this reason Over 1.00 N
Dater Services,Swbd.,MCC&Panelboards Z
0-2.00 Amp.Under 600 V
Signature 201 - 1000 Amp,Under 600 V
Over 1000 Amp.or Over 60.0 V
rl Exemption.for Reg.Maint:Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign.with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law'
i
h Ci
B
Sign Sgn rancCircuits
for the following reason(Section 7031.5,Business and Professions Additional
ki,as owner of the property,will do the work and the structureMisc.Conduits.&Conductorsnot intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ -I.
d Professions x• ___ _ _d
CONSTRUCTION LENDING.AGENCY
I hereby affirm that there is a construction lending agency for the f+'s
performance of the work for which this.permit Is issued(Sec.3097, PERMIT.FEE (Sub Total),
Civ.C.).
PLAN CHECKING FEE l
Lender's Name --
PERMIT ISSUING FEE
Lender's Address
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
properM,for inspection•purp ea. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PerMittLye Date