HomeMy Public PortalAbout6210 SULTANA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 120.0019 DPW 3/87
I hereby affirm that I have a certificate of consent to self .7E APPLICATION FOR ELECTRICAL PERMIT O
insure,tdr a certificate of Workers'Compensation Insurance, ! COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a cnrtified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN J,OB
❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
❑
$ -_Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ LOCALITY
tion department. Multi-family Sq. Ft. NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec =_Light. Sw.Y FIRAM NAME Ze/
.t• _ �a
COMPENSATION INSURANCE C MADDRESS
First 20
Q S �st�/GL
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(This section need not be completed if the work Involved by Total No. If Additional CITY / Tel. No.
the permit is for one hundred dollars($100)or less.) PIAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws.
rJ Additional
Total No.Z CITY Tel. No.
Date AF/ Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer W.M.— ADDRESS
with comply with such provisions or this permit shall be
deemed revoked. Top FAU -/—W.H. CITY /G ��� TGTel. No.
LICENSED CONTRACTORS DECLARATION Hood Fan —Other—J �� &C LICENSE OR
Disp. +�- Room Air Cond. �
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER �OD Class. �=��J
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PRO SSED BY >_
and Professions Code,and my license is in full force and effect. � y o-
t� Size&Type HP, KW, KVA, or KVAR ,� ri'� Ci'�-�- .1 O
License Number Li . Class U Up to 1 Incl. FINAL U
1-14� �� /ir"c-- Over 1 to 10 Incl. DATE S 9.- g VALIDATION cc
Contract �e Over 10 to 50 In .❑ FINAL
F
I am exempt under Sec. Over 50 to 100 Inc. BY ����%��y� W
B.&P.C. for this reason Over 100 " -_`�/_ d
Services, Swbd., MCC&Panelboards O
No> Z
Date: 0-200 Amp. Under 600 V Z
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp, or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances -
HOME OWNER-BUILDER DECLARATION i
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit !:!: s
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
11
Professions Code):
Misc. Conduits&Conductors
IDI, as owner of the property, will do the work and the -"-!
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ® t a",-AL. 7 9 Q
Business and Professions Code). %
CONSTRUCTION LENDING AGENCY - • �-
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE A-5 - - -
Lender's Address
I certify that I have read this application and state that the TOTAL FEE ��, �� l
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of th' County to enter upon
the obey ����per� ection pur ses.��
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signature of Permittee Date as