HomeMy Public PortalAbout5120 ROSEVALE DR_Electrical__ WORKER3 COMPENSATION DECLARATION 70M63 10,61 APPLICATION FOR ELECTRICAL PERMIT
• I w&afflrm that I have a certificate of consent to sell assure flow
or a certificate of V.brkers Compensation Insurance or a cerbfed COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
copy thereof(Sec 3800 Lab C) fl
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Pd W`(L i ,p,n�,y ll�.r, �l FOR APPLICANT TO FILL IN JOB �O Q`
Certaletl copy a hereby furrmted New Residential Brigs It Fb1d�,� EACH NO FEE ADDRE
Vri❑ Certdletl.copy Is filed mth the county building mspectKm 1 d 2-Family, Scl Ftp $ — S OCAIIfV
department Muai-family, SQ Ft — NEAREST
�'• 7GROSS ST 4a Race? re
Date esenommmirgos R OR
` 1 'FIRM NAME W C �-
CERTIFICATE OF EXEMPTION FROM WORKERS \ 1
COMPENSATION INSURANCE Outlets Rec— Light MAIL Sw MAIL
ADDRESS
(This section need not be completed If the work Involved by the First 20
permit Is for one IKlntlrotl dollars ($100)or lees)
Total No Additional CITY Tel No
I certify that in the performance of the work for which the permit PLAN CHECK
is Issued I shall not employ any person In any manner so as to APPLICANT
become subject to the Workers Campensetlon Laws Lighting Fixtures First 20 ADDRESS
Total No AdditionalCITY Tel-No
Date Pppipant FIxed Appliances Not Over 1 HP PERMR
NOTICE TO APPLICANT It after making the Certificate d
Exemption you shwId become subjact to the Workers Compensation Range— Heater_ DW _ APPLCAttT
prwtaons of the Labor Code you must forthrnth comply 1Nth such Oven _ Dryer — W M — ADDRESS '
proyemona or the permit shall be deemed revoked Top _ FAU _ WH _
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel No
I hereby affirm that I am licensed under provepns of Chapter 9 Dep mec — Roan Air Cond �p NUMBER ( �0D
(comence g with Shon 7000)of On mion 3 d the Business and
Professions Code and mylicenselicense Is In full force and effect Power Apparatus 8 Large Appliances DISTRICT NO PROCE eY y
License Nurnber l LIC Class C-1 c) Sue d Type HP KW KVA or KVAR 15� D� 8
Up to 1 Ind FINAL
Over 1 to 10 Incl
ConDate , Over 10 to 50 Inc]
❑ I am exampl under Sec Over 50 to 100 Inc Fi
BV W
BSPC for this reason Over 100 a
Services Swbd MCC 6 Panelboards ► Z
Date 0- 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 8DO V
❑ Exemption forRep Maim Elect Over 1000 Amp or Over 600 V
SINGLE FAMILY Temp Power Pole d Appurtenances '
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circwt
I hereby affirm that I am exempt frcm tie Contractor Licemee Law
for the following reason(Section 7031 5 Business and Professors Additional Sign Branch Circuits
Code)
❑ Mac Conduits s Conductors ;S6 8 6 1 A
aI as owner of the property do the work and the structure Oder (Sea Complete Fee Schedule) —
not feendetl or offered foror sale (Section 7044 &Istrleas , # e e e e '2
and Prolesepna Coda)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructlpn lending agency for the
perf Civ Crmancs d the work for which the permit Is mss d(Sec 3097 PERMIT FEE (Sub-Total) I e 987.02
PLAN CHECKING FEE
Lenders Name e e e 87. 02 5
PERMIT ISSUING FEE
1Lcertify that I endef a Address read the applpabon and state that the above TOTAL FEE 04„1 5 t 8 7
Irtfarmaban m correct I agree to comply wrath all Ccunry ordinances
and State lawn r041114 Electrical wiring and hereby authorize
representatives my to enter upon the above-mentenad
for rposes
tj 41-4
S to o Perm
121 Data ` ��- SEE REVERSE FOR EXPLANATORY LANGUAGE