HomeMy Public PortalAbout5217 WILLMONTE AVE_Electrical__ v ORICERS'COMPENSATION DECLARATION 20-0019D 3/� APPLICATION FOR ELECTRICAL PERMIT
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I. I h�reb�ct�rm that I have a certificate of consent to self •�E.e�
insure, or a+tertificate of Workers'..Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof(Sec. 3800, Lab. C.) , ` ',
Policy-No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS /� Iw
❑Certified copy is Hereby furnished. New Residential Bldgs. &Pools EACH + NO.. FEE
$ _ $
FI tion
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&Certified copy is filed with the county building inspec- 1 2-Family, Sq. Ft.
tion department. Multi-family Sq. Ft.
NEAREST
CROSS Residential Swimming Pools OWNER OR lee Date Applicant FIRM NAME dJW S ISP...?
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec__15_Light_8_Sw.4__. MAIL S-217 AJ
COMPENSATION INSURANCE rpZ. ADDRESS
(TpY L�L -�.
his section need not be com leted if the work involved b Total No.. L First 20 Additional CITY Tel. No.
I
the permit Is for one hundred dollars:(;100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall riot employ any person in any manner Lighting Fixtures First 20 o ADDRESS
so as to become subject to the Workers'Compensation Laws.
Additional
Total No. CITY - Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT •
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
Exemption,you should become subject to the Workers' Range— Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be I Top FAU —W.H.'—
deem.ed
.'—
deemed revoked. Hood — Fan —Other— CITY 01 Tel. No.
LICENSED CONTRACTORS DECLARATION Dis -32 � LICENSE OR
.I hereby affirm that I am licensed under provisigns of Chapter 9 p —�- Room Air Cond. — REG. NUMBER Class.
,(commencing with Section 7000)of Division 3 of the Business Power.Apparatus&Large Appliances DISTRICT NO. OC SED BY .a
and Professions Code,and my license is in fall,force and effect.
Size&Type HP, KW, KVA, or KVAR _ e� 0' .
License Number Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 incl. DATE VALIDATION o
Contractor Date Over 10 to 50 Incl. FINAL U
❑ .1 am exempt under Sec. Over 50 to 100 Inc'. BY W
B.&P.C. for this reason Over 100 N
Date: Services MCC&Panelboards Z
0-200 Amp. Under,4W
Signature 201 - 000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
Pcuit +
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch C _
Law for the following reason (Section 7031.5,'Business and Additional Sign Branch Circuits
Professions Code): ---
Misc. Conduits&Conductors
I, 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)_
Business and Professions Code).
CONSTRUCTION LENDING AGENCY j x 5 1.42
I hereby affirm that there is a construction lending agency for YIYI_
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE i 1_ - "li,w
Lender's Name PERMIT ISSUING FEE er _
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-mentioned prop t for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig lure of Permit ee `D to ®'