HomeMy Public PortalAbout4851 ARDEN DR_Electrical__ .WORKER'S COMPENSATION DECLARATION 20-0019 DPW(t2-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec 800 Lab.C.) )�/
Policy No. Company "V o r'"� FOR APPLICANT TO FILL IN JOB ADDRESS .] v
❑ Certified copy is hereby furnished. New Residential Bldgs.&Po NO. EACH FEE
$ $ LOCALITY G
Certified copy is filed with the cunt —obuilding insp coon 1&2-Family,Sq.Ft. `� _ NEAREST
depart '�` Multi-family Sq.Ft. CROSS ST.
Date Applicant y /Y Residential Swimming Pools ASSESSOR G �
MAP BOOK ��a PAGEd/� PARCELL/�/Q
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. FIRM OWN NAM R ,��
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.)
Total No. Additional ADDRESSy,_2 /fZ_55w�
I certify that in the performance of the work for which this permit CITY ,tom Tel.No.
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 PANT
Total No. Additional
ADDRESS !�
Date Applicant g�
NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY kf 4�- Tel.No.
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith_comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. /
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. 7
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. A
LICENSE OR Class. }
Over 50 t0 100 Ind. REG.NUMBER a
Over 100 DISTRICT NO. PRO SSED BY 0
License Number � Lic.Class� ��O C�ti�����•-'� V
Services,Swbd.,MCC&Panelboards FINAL
Contractor Date 0-399 Amp.Under 600 V ATE❑ 0 400-1000 Amp.Under 600 V ` V
I am exempt under Sec. VALIDATION
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits
El. Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits G
SINGLE FAMILYH-
Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit .j s; -t1 1_�
° .'I
hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits y S
Code): i
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOT!AL -156 `s 9q,,,``
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t_; `i_;tC:
, j .4.`=1 i
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, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �b
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this Cou ty to enter upon the above-mentioned property
for inspe I pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE