HomeMy Public PortalAbout5570 SULTANA AVE_Electrical__ WORKERS'COMPENSATtONDECLARATION 76A653 63 (2E0)
CEBAPPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of cement to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
Insure or a certificate of Workers'Compensation Insurance,or ,
qd c py thereof(Sec 3800,Lab C)
p '/n J�• FOR APPLICANT TO FILL IN JOB
Policy No v Company �' f C �"^��r New Residential Bldgs &Pools EACH NO FEE ADDRESS J r
❑ Certi ad ct hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY •P / 1 `
Certified co Multi-femdy Sq Ft NEAREST
dap en copy hied with the county building inspects CROSS ST
Residential Swimming Pools, OWNER OR �
FIRM NAME jj�� �? If ,
Date/Applicant` w Outlets Rn_Light Sw MAIL
/I1 C P,-,i'lSLrC vfltl
CERTIFICATE OF EXEMPTION FROM WORKERS' —Rost Zio—
Total No Additional CITY Pe �9 /e f al No T J_
I COMPENSATION INSURANCE 1 i
- . PLAN CHECK LL
(Thu wctlon need not be completed If the work involved APPLICANT >
by the permit is for one hundred dollen (SI00) or less) Lighting Fixtures First 20 ADDRESS cc
Total No Additional 4
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No
permit n issued, 1 shell not employ any person in any manner PERMIT ),.� �f �+/Pl // 2
so as to become subject to the Workers'Compensation Laws Range_ Heater_DW _ APPLICANT �r L+ /
Oven _ Dryer_W M ADDRESS �1 I mo/ t v/6 W
Date Applicant Top _ FAU _W H _ C�&! '
f �
Hood _ Fan _Other_ Tel Nol
NOTICE TO APPLICANT If, after making thin Certificate of Disp _ Room Air Cond_ c R
Exemption you should become subject to the Workers' i - REG NUMBER 0 {11 Class � I
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PRO ESSP BY
with comply with such provisions or this permit shall be SI! &�HP,KW, KVA,or KVA j+UQ
deemed revoked
Up to 1 Incl S
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATE VALIDATION
Over 10 to 50 Incl
I hereby affirm that i am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000) of Division 3 of the Bust Over 1 G By 0
ness and Profession Code, and my license is in full force and Z
effect Services r
U �J �, 0-200 Amp Under 600 V �'y
'license Number c Claes
irYr, / / _ 201-1000 A m Under r 0 V
Contactor / L Deta Over 1000 Amp or Over 600 V ' S
HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenances -
7 hereby affirm that I am exempt from the Contactors Sign with One Branch Circuit 1
Licene Law for the following reason (Section 7031 5, Bust Additional Sign Branch Circuits
nese and Professions Code) s 'a
Misc Conduits&Conductors
❑ 1,res owner of the property will do the work and the Other (See Complete Fee Schedule)— 4f ""I t
strycture is not intended or offered for sale (Section i' i I�1�,tF
7046;Bus[neu end property will
Code) ` i �jy�p
4 CONS
UCTION LENDING AOLNCY �`� ��,f1M`7
I hereby affirm that there u a construction lending agency I�I�+'1"��� i
for the performance o! the work for which this perms[ is PERMIT FEE (SuTF")
'
ysued,,((Sec 3097 Civ C) i i�1y
f.ende{''s Neme PLAN CHECKING FEE IOne Fourth PerQ a 4`�1
Londe s Address PERMIT ISSUING FEE "
1 certify that I have read this application and state that the TOTAL FEE above Informatio
n is correct 1 agree to comply with all County r
ordinances and State laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon '
the above m ti'o�ne-/dyproperty for rnpect purj`p�osn SEE REVERSE FOR EXPLANATORY LANGUAGE r
i if s . ;J�
Stgnstureofpermittee Date '