HomeMy Public PortalAbout5702 OAK AVE_Electrical_1/10/1991_WORKERS' COMPENSATION DECLARATION
d hereby affirm that I have a certificate of consent to self insure,
or, a ce to of Workers' Compen h. Insurance, or a cerci ied
copy f ec. 3800 . C.)
Poli ¢ Com
or
Certified copy is hereby furnished.
Cert ied copy is filed with^e count uilding inspec n
de rtme t.
Date Applica
CERTIFICATE OF EXEMOI FROM W ERS'
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by the
permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should became subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Licen Numb Lia Clasa
/7/F/Contra Date
❑ am exempt and ec.
BAP.C. for this reason
❑ate:
Signature
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions
Code):
❑ I, as owner of the property, will do the work and the structure
is not intended or offered for sale (Section 7044, 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 (Sec. 3097,
Civ. C.):
Lender's Name
Lender's Address
I certify that I have read this application and state that the above
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
gen tativesojsCounty to enter upon the ag6ve-met eC n purposesV///ure of ermittee Deie
76A663 10/81
CE -806G
APPLICATION FOR ELECTRICAL PERMIT
BUILDING AND SAFETY
COUNTY OF LOS ANGELES
FOR APPLICANT TO FILL IN
New Residential Bldgs. & Pools EACH NO.
1 & 2 -Family, Sq. Ft. $ — $
Multi -family Sq. Ft.
Residential Swimming Pools .
Outlets: Rec—L Light Sw. _
First 20
Total No. Additional
Lighting Fixtures
First 20
Additional
Total No.
Fixed Appliances Not Over
1 HP
Range_ Heater_
D.W. _
Oven _ Dryer _
W.M. _
Top — FAU _
W.H. _
Hood — Fan —
Other_.
Disp. — Room Air Cond. —
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over 1 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Panelboards
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)
PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
1 JOB
FEE I ADDRESSa
LOCALITY /
NEAREST
CROSS ST. �.
OWNOR
FIERRM NAME
MAIL � �j
ADORES ,/,,,;pL`G,(I/. GGG��f///111 ��V..r1q�
CITY` Ny / fiLl �/_'M'i V
PLAN E %- 7
APPLICANT
ADDRESS
CITY Tel. No.PERM
APPLI
ICA
LADDRESSTY . No�NSE
REG. NUMBER
DISTRICT NO. PROC SSED BY d
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FINAL / �7 J �3/ �
� DATE // / VALIDATION Q
FINAL '�',� U
BYCn
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ANT
„307 ,_I
i 1 ITE"E.
TA AL �2-_r' a v�
CHECK �"..
(Sub -Total) / D 8d CHANGE
13—
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4947 1 AM11�l�`
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