HomeMy Public PortalAbout5552 ROBINHOOD AVE_Electrical__ WORKER'SCOMP>fJSATK)N DECORATION 7&&M DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certlfloate cd oonsent to self Insure,
or a certificate of worker's Conipensatlon Insurance, or a oertllled COUNTY OF LOS ANGELES `DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.)_
No. Company POR APPLrA1Ni TO RLL N JOAl)DRE88 3•�CY-7
El Certffled copy Is hereby fumlahed. New Reeldontlal Bkigs.&Pools NO. EACH FEE LOCALITYG�Vl7 G
❑ CertNled copy Is filed with the county bulk ing IrmpeodQn 1 &2-Fem[�y,Sq.Ft — $ i NEAREST
depantmerrt MunNamlly 3q.Ft CF4068 ST.
Dote Applicant Raaklentlal Swlmmtng Poole MA
Boy PAGE PARCEL��
=Fr-ATE OF EXEMPTION FROM WORKERS' �/ G
OWN ER OR
COMPENSATION INSURANCE Outlets:Roc. LVgtrt FI st 20 1�0! /72q o
Flwr NAtWE
(Thla seoUori need not be oornpleted H the work Involved by the / 7 ,�Egg
permit le for one hundred dollars($100}or lose.) TOS�' ���
I certlty that In the performance of the work for whloh thle permit CITY TeL No- _
Is leaued, I shall not employ any person In any manner so as to PLAN Ct-IECK
become subject to the Worker' Compensadlon Laws. Lightlng Ftxtu� Rrat 20 ApPt wr
T No.
ADDRESS
Data Applk)&M 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY TeL No.
Exemptlon,you should become subject to the Workers' Compensation O O 3 HP.
prgv)elone of the Labor Code, you must forthwith comply wlth such PAPP�uCmwr
provlslons or thla permit shall be deemed revoker ed. PowApparatus 8 Large Appliances
LICENSED COMRACTORS DECL RA71ON Stze J4 Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provlslons of Chapter B Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Thi No.
Proleaalons Code,and my Ilcenee Is In full force and effect. Over 10 to 60 Ind.
Over 60 to 100 Ind. RECL � a
Over 100 DISTRICT NO. BY 8
Lk�Number Lic.Cleve
Q
Contraotor Dote TP 0 �np.l�V� ��
❑ I am exempt under Sec. 400-1000 Amp.Under 000 V 5U
yAUDAnON
Over 10oQ_Am p.or Over 600 V FUTAL W
B:hP.c.for this reasonBY BRANCH CIRCUIT FEES N co
Date: 16A,or 20A, 12OV,Lighting or Recept. z
1 To 10 Branch Circults
Signature 11 To 40 Branch Clrcults
41 Or Mare Branch Ctratb
El Exemption for Reg.M" Elect 16A,261 2DW To A Br.Ckouka
r'Y
SINGLE FAMILY Temp,Power Poi@ S Appurtenances
HOME OWNED BUILDER DECLARATION sign with One Branch grcun ►4.�;Y.a
I hereby affirm that I am exempt from the Contr4otor's License Law t
for thefollowing reason (Section 7031.6, Business and Profeaalons Additional Sign Branch Ctrculta
Code): 33 [e.tc 1575.70n
I, as ower of the property,will do the work and the structure Misc.Conducts&C x-duotm 1 DDE
kr
Is not Intended or offered for sale (Section 7044, Buslnesa Other(See Complete Fee Sohadu}e) , TOTIPL 155 - 70
and Professions Code). C�ECK i L�
CONSTRUCTION LENDING AGENCY 1- "T,
I hereby affirm that there Is a construction lending agency for the 1�lt7fTM]C �[Ifl
performance of the work for which this permlt Is Issued (Sec. 3097, PERMFr FEE (Sub-Total) ES
Clv.C.)
PLAN CHECK]NG FEE -0)01
3/24/79
Lender's Name /_
PERMIT ISSUING FEE f/ 9622 1 Am11:131
Lenders Address
I owtlfy that I have read this appJlc t and under penalty of perdu:y state TOTAL FEE
that the above Information Is oorrect I agree to comply with all CWnty
ord!nwxms end State laws regulatlng Electrical wtring,and hereby authorize
repraoentatfveo of chic County to enter upon the above-rnentkxred property
for lRepeUbn punxew SEE REVERSE FOR E)UM- NATORY LANOUAOf
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