HomeMy Public PortalAbout5935 ROWLAND AVE_Electrical__ gel
WORKERS'COMPINSATIO"DECLARATION 8� lo/Bl i
APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, I COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lob. C.) f
Policy No. Company I FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS 77
PY � Y New Residential Bldgs. &Pools
Certified copy is filed with the county building inspec- I &2-Family, Sq. Ft. $ = $ LOCALITY L� PjS r v 0 AS
tion department. Multi-family Sq. Ft. NEAREST
CROSS T. (.94SJ N
Residential Swimming Pools
Date Applicant I OWNOR
R p1 I_ '
FIRM J/ iv
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec.�Light Sw._ IL
COMPENSATION INSURANCE ADDRESS �J- 'IC
Ts section neenote completed if the work involved b First 20
( hitineed b
p Y l Total No. Additional CITY � �� � ,�.-� Tel. No.
the Ifermit is for one hundred dollars($100)or less.)
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. I Lighting Fixtures. First 20 ADDRESS
Total No. Additional
DateJ�2_544/applicant CITY Tel. No.
NOTICE TO APPLICANT: If, after ing this erfificate of Fixed Appliances Not Over 1 HP PERMIT e, c
Exemption, you should become subject to he Workers' Range— Heater—D.W. APPLICANT l� °J Q E ��-6�MP—IL
Compensation provisions of the Labor Code, you Must forth- Oven —Dryer _W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _Other_ CITY 10, e®U )- Tel. No.01 l
LICENSED CONTRACTORS DECLARATION LICENSE OR e
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room.Air Cond. REG. NUMBER p& Class.G_r
(commencing with Section 7000)of Division 3 of the Business DISTRICT N PROCESS
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances A
Size&Type HP, KW, KVA, or WARl�J
License Number Z 17 Lic. Class Up to 1 Incl. FINAL ,� ✓ to
[� Lam'•L 3^6 Over 1 to 10 Incl. DATE '
Contractor Date ®® FINA VALI TION �
❑ Over 10 to 50 Incl.
I am exempt under Sec. Over 50 to 100 Inc. BY NO
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1.000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
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 Additional Sign Branch Circuits r
Law for the following reason (Section 7031.5, Business and 6 1 6 4 A
Professions Code):
Misc. Conduits&Conductors # o o. 0 0 0 2
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ , ( o o45.75
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for j 2,24-86
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 35- LS
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE d
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
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- entioned pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
17•-2.3 r O�o
Signature Permi ee I I Date