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HomeMy Public PortalAbout5302 ZADELL AVE_Electrical_10/22/1982_ WORKERS'COMPENSATION DECLARATION IOM63 10/81 I hereby affirm that I have a certificate of consent to self FE-806G APn0 Ln OCA" 0 FOR EI CUBICAL PERMIT insure, or a certificate-of Workers'Compensation Insurance, COUNTY OF LOS ANGELES � BUILDING AND SAFETY oor+1 a certified copy thereof(Sec. 3800, Lab. C.) I / P�ol cylNo 0 7a ompany FOR APPLICANT TO FILL IN JOB r-2 ®fg / Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS`s7 I Fa EU : — IQ Certified copy is filed with-the county building inspec- 1 &2-Family' S q• Ft. $ $ LOCALITY'NEAREST tion department. Multi-family Sq. Ft. — /0_ZZ_'9?_ © Residential Swimming Pools CROSS ST. OWNER OR Date. Applicant ��-���G FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ AMAIL DDRESS COMPENSATION INSURANCE _ ' First 20 the permit is for one hundred dollars($100)or less.) PLA I certify that:in the performance of the work for which this I A PLICANTK permit is issued; I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. j Lighting Fixtures First 20 ADDRESS 1 Total No. Additional CITY Tel..No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of I Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range_ Heater_D.W. APPLICANT�� ��- -�• Compensation provisions of the Labor Code, you must forth- Oven —Dryer _V,W.M.— ADDRESS-&qZ/ _; . jOt6 G 19j�'UO with comply with such provisions or this permit shall be Top _ FAU —W.H. — CITY Tel. No. b deemed revoked. Hood _ Fan _Other— 7, P� of 7-SZ S LICENSED CONTRACTORS DECLARATION Q 3 LICENSE OR /7 I hereby affirm that I am licensed under provisions of Chapter 9 [ Disp. _ Room Air Cond. REG. NUMML_6 $ Class.��/ (commencing with Section 7000)of Division 3 of the Business DISTRICT.NO. / PROCES D BY Power Apparatus&Large Appliances , and Professions Code,and my license is in full force and effect. �i � Size&Type HP, KW, KV.A, or KVAR' S' O 'I License er Lic: Class � 0 Up to 1 Incl. DATE lQ-i ,? � Contractor ate ©��Zr �- Over 1 to 10 Incl. FINAL S _�r VALIDATION 0 Over 10 to 50 Incl. I am exempt under Sec. Over.50'to 100 Inc. BY , ,, LU B:&P.C: for this reason j. Over T00 V U) Date: Services, Swbd., MCC&Panelboards i; 0 -200 Amp. Under 600 V D ' Signature I 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V 2 Exemption for Reg, Maint..Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances. ' 7=m707, 1 A HOME OWNER-BUILDER DECLARATION i {{ Sign with One Branch Circuit o 0 0 0 0 I hereby affirm that I am exempt from the Contractor's License I Additional Sign Branch Circuits ' 2 Law for the following reason (Section,7031.5, Business and Professions Code): 2 o c 2 6 5 0 Misc. Conduits&Conductors I, as owner of the property, will.do the work and the o 0 0 2 5.0 cz� structure is not intended for offered for sale (Section Other(See Complete Fee Schedule)- 7044, Business and Professions Code). I 1 0 2'2:-s 2 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 f Lender's Address 1 certify that I have read this application and state that the TOTAL FEE 5 above information is correct. I agree to comply with all County ! i ordinances and State laws regulating Electrical wiring, and i hereby au thorize representatives of this County yto enter upon ave-ment'one pro tir or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,0-ZZ- OZ Signature of Per ittee Date j 1 �