HomeMy Public PortalAbout4853 ARDEN DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm th8t I have a certificate of consent to self insure, 76A663
or a certificate of WBrker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.) ��-�
Policy NO.,y000m pang FOR APPLICANT TO FILL IN JOB f " �/
ADDRESS I/
Certified'copy is hereby furnished. New Residential Bldgs.&Pool NO. EACH FEE
$ $ LOCALITY e
Certified copy is filed with the coun building ins ection 1 &2-Family,Sq.Ft. _ NEAREST
de p rt n Multi-family Sq.Ft. CROSS ST.
_M S� /I/ Residential Swimming Pools ASSESSOR
Date Applicant [[Y MAP BOOK PAGE d PARCEL OV
NER
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. _ FOIRM NAME
COMPENSATION INSURANCE -
First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS3a
permit is for one hundred dollars(5100)or less.)
I certify that in the performance of the work for which this permit CITY :5Ze04.r N Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT CHECK
Total No. Additional
ADDRESS _
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. olf
provisions of the Labor Code, you must forthwith comply with such PERMIT / f� /Jv /
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT j ((,�; e
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS $d 1
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. `��A
(commencing with Section 7000) of Division 3 of the Business and CITY A Z V y, Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
LICENSE B Class.e--14:;;,
Over 50 to 100 Incl. REG.NUMBER � � � 11.
License Number Lic.Class �r Over 100 DISTRICT NO. P O SSED BY 0
Services,Swbd.,MCC&PanelboardsD� � 9GaG� I=Contractor o!� l�Y! 'Date v-� 0-399 Amp.Under 600 V FINAL 0
/��
DATE
400-1000 Amp.Under 600 V❑ VALIDATION V I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL IZ
B.&P.C.for this reason BRANCH CIRCUIT FEES BY W
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
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp. Power Pole&Appurtenances k-?t•F:!as
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law g 13s���`I_S
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors F__)TAL 156 901
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t _
and Professions Code). , t_. _.!; 15 ,` �_'
CONSTRUCTION LENDING AGENCY C"HAI TE .00
l
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 + � s `. ae s
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 County enter upon the above-mentioned property
for inspection pur s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUll PERMITTEE DATE