HomeMy Public PortalAbout6334 TRELAWNEY AVE_Electrical_7/26/1988_service amps KERS COMPENSATION DECLARATION �19 DPW_�� APPLICATION FOR ELECTRICAL PERMIT O
r I vh.46y firm that I have a certificate of consent to self aaoec
insure or a certificate of Workers' Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
w a celtlfled cop_ y tFj�{.s(om 3800-la
Pob /N6nD l�(� Company J_ �� "i FOR APPDGNT TO FILL W JOB 3 $4 /�
Certified copy is hereby furnished New Residential Bldgs 6 Pools EACH NO FEE '�� / `
®.E9RLJ
ified copy is filed with the county building inspec 18 2 Family Sq Ft S = S LOCALITY G
hon deponment Multi-family Sq Ft NEAREST
OT(Ijy,F Residential Swimming Pools COWNERS
Dote Apphcom OR p
♦ FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_ ♦ MAIL
COMPENSATION INSURANCE Fust ADDRESS
(This sadlon need not be completed d the work in"hred by Total No Additional CITY Tel No
the permit Is for one hundred dollars ($100)or Ins ) ♦ PIAN
1 certify that in the performance of the work for which this PLAN CHECK
AM
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20 ADDRESS
Additional
Date Applicant Total No CITU Tel No
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of
Exemption, you should become subject to the Workers Range— Heater—DW — APPLICATION — e
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS .2_
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood — Fan —Other— CITY el N
LICENSED CONTRACTORS DECLARATIONLICENSE OR
I hereby affirm that I am licensed under provmore of Chapter 9 Disp L iR�IF Au Cond �� REG NUMBER v Class (7111 4D
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO - / PROCESeDBY �T
and Profess.om,Code and my license is in full force and effect
e, Size 8 Type HP KW ICVA w KVAR �.J t lJ b O
Ucense Number I,r Class Up to 1 Incl FINAL
_� A 727 Over 1 to IO Ind DATE VA TION ¢O
Contractor �/��r,�Dote Over 10 to 50 Incl H
OFINA 0
I am exempt under Sac Over 50 to 100 Inc BY/y/ W
B 8P C for this reason Over 100 O_
Services Swbd , MCC 8 Ponelboords N
Date 0-200 Amp Under 600 V U
Signature 201 1000 Amp Under 600V
D Exemption for Reg MaiOver 1000 Amp or Over 600 V
Maim Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s license
Law far the following reason (Section 7031 5, Business and Additional Sign Branch Circuits '�0 2 7 9 A
Professions Code) # e e e e e '2
i
I, as owner of the property will do the work and the Misc Conduits 8 Conductors I --- 29..0,0
structure is not intended or offered for sole(Section 704, Other (See Complete Fee Schedule)_ , -,- - 29005
Business and Professions Code)
CONSTRUCTION LENDING AGENCY O 7 2 61t-8 S
I hereby affirm that there is a construction lending agency for
the performance of the work far which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097, Civ C )
PLAN CHECKING FEE
Lender s Name PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
above mf mat n is correct I agree to comply with all County
ordma sand State laws regular g Electncol wrong and
4robor¢e repro ryes humy raenter uponmention rope yfinspurposesEE REVERSE FOR EXPLANATORY LANGUAGE
f Permmee Dote �� ®s