HomeMy Public PortalAbout6343 TRELAWNEY AVE_Electrical_7/16/1986_outlets WORKERS'COMPENSATIONDECLARATION 76A678A06CE 63
APPLICATION FOR ELECTRICAL PERMIT {�
k (2 00) U
Lhereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or _
baa cc's !fled copy thereof(Sec 3800,Lab C)
Policy Novy ��JTompany!ee'e*ON/ -7r-"` ' FOR APPLICANT TO FILL IN 3pg n
New Residential Bldgs &Pools EACH NO FEE ADDRESS Re�f1[vNe
Certified copy is hereby furnished 1 &2 Family.Sq Ft $ — $ LOCALITY Te/)f le Pr f
dCertified epartment Residential is flMulti-family Sq Ft ed with the county building ins action CRST
OWNER OR
Residential Swimming Pools
Date 7_/r_3 bA hcent / FIRM NAME 2 F- �.j /(/e�SVN
pp Outlets Rec LLight Sw MAIL /
CERTIFICATE OF EXEMPTION FROM WORKERS' '3 first 20 ADDRESS fx 3�
COMPENSATION INSURANCE Total No Additional CCTV sf (dr'� Tel No - }
PLAN CHECK CJ
is sectiUUU8
on need not be completed If the work involved 'APPLICANT
(Th
by the permit u for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS
Total No Additional O
issued, I shall not employ any person ,n any manner PERMIT
I certify that ,n the performance of the work far which this Fixed Appliances Not Over 1 HP CITY Tel No
Cd G
permit is w
so as to become subject to the Workers Compensation Lawn Range_Heater_D W APPLICANT �dNNO2 A
Oven _ Dryer_W M ADDRESS 9 i N NCi�N/�� 2
Date Applicant Top _ FAU _WH _
Hood _ Fen _Other_ CITY /Q n� Tel No (�f
NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond— LICENSE �.�
Exemption, you should become subject to the Workers' REG NUMBER 03 -SCleas
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES ED BY
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP,KW, KVA,or KVA
Up to 1 Incl FINAL
Over 1 to 10 Incl DATE �J
LICENSED CONTRACTORS DECLARATION Over 10 to 60 Incl
hereby affirm that I am licensed under provisions of Chapter Over 60 to 100 Inc FINA
(commencing with Section 7000)of Division 3 of the Bus, Over 100 BV
and Professions Code, and my license is ,n full force and
ect Services
ansa Number 4149373SLin Class 0 200 Amp Under 600 V
CJ
tf 201 1000 Amp Under 600 V
tractor 66NAf0 Z Data 7-��a Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole& 8 5 0 5 6 A
Appurtenances
aby affirm that I am exempt from the Contractor's Sign with One Branch Circuit # a a 2
se Law for the followingreason Section 7031 5, Bus, Additional Sign Branch Circuits ,
nd Profnuons Code) ' ( I a a 1 3 5 0
Misc Conduits Conductors i a • • 1 3505
as owner of the property will do the work and the
Other(See Complete Fee Schedule)—
ructure ,s not intended or offered for sale (Section Q •] 1 6t-86
4, Business and Professions Code)
CONSTRUCTION LENDING AGENCY
affirm that there ,s a construction lending agency
performance of the work for which this permit is PERMIT FEE (Sub-Total)
ec 3097 Civ C)
Name PLAN CHECKING FEE (One Fourth Permit Fee)
ddress PERMIT ISSUING FEE
t I have read this application and state that the TOTAL FEE
ation is correct I agree to comply with all County 13
nd State laws regulating Electrical wiring, and
rize representatives of this County to enter upon
honed property for ins c ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
; 7- s-
of Permittee Date