HomeMy Public PortalAbout10684 ARROWOOD ST_Electrical_6/7/1993_amp service panel WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 ,.APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Wo°Ker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3860 Lab.C.)
ElCertified
No. x Company FOR APPLICANT TO FILL IN JOB
ADDRESS o vd
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY e
❑ Certified co is filed with the count building inspection 1&2-Family,Sq.Ft.
PY Y 9 P — NEAREST
department. Multi-family Sq.Ft. CROSS ST. Mal
Date Applicant Residential Swimming Pools ASSESSOR p�}}
MAP BOOK ,/ C7� PAGE 2&90 1 PARCWII// se
IIER
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Svv. OFOOIRM NAME �f�o
COMPENSATION INSURANCE First 2.
(This section need not be completed if the work involved by the
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permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS r O
I certify that in the performance of the work for which this permit CITY To 01 Ile— Tel.No
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPCHECK
LICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with Such. PERMIT A�G�
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT O'
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel,No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. >_REG.NUMBBER
Over 50 to 100 Incl. LICENSE Class.
�
Over 100 DISTRICT NO. SSED BY ' O
License Number Lic.Class
Services,Swbd.,
M/. P nel ards
Contractor Date 0-399finder� FINAL 0
/ DATE ^
El 400-1000 Amp.Under 600 V
I am exempt under Sec. VALIDATION LLI
Over 1000 Amp.or Over 600 V FINAL Q
B.&P.C.for this reason BRANCH CIRCUIT FEES BY W
Date: 15A,or 20A,120V,Lighting or Recept. (J _
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El
41 Or More Branch Circuits
Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br,Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit a
I hereby affirm that I aln exempt from the Contractor's License Law g iii-`'I°$
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 2,
Code): 7%J0 J i r, h I
.➢91 a�.`.
l I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors ITEMS
C— is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) T T A
and Professions Code). i -
65
CONSTRUCTION LENDING AGENCY L. 61.66 v
1 hereby affirm that there is a construction lending agency for the '(�( Ji
performance of the work for.which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
Lender's Name 4..10110-000 1
PERMIT ISSUING FEES j�: %tn
c �s.__ 3 (� tea_,0
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 to enter upon the above-mentioned property
for inspe ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATURE OF PER tTTEE DATE