HomeMy Public PortalAbout6111 AVON AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT Ll
76A663
I hereby affirm thaY9 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.3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pgols NO: EACH FEE
J / LOCALITY
❑ Certified co Is filed with the count building inspection 1 &2-Family,Sq.Ft.` 2471-
department.
TT� — $ $
PY Y 9 P _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR _�_-�p J
MAP BOOK p (O PAGE Do PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OP.M NAOR
ME N
COMPENSATION INSURANCE
�q
(This section need not be completed First 20 MAIL
the work involved by the ADDRESS a� Ir10 LetWepermit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK /v
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
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
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.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to 100 Incl. LICENSE OR Class.
REG.NUMBER 0-
Over
Over 100 DISTRICT NO. P OC SED BY O
License Number Lic.Class V
Services,Swbd.,MCC&Panelboards W.
0-399 Amp.Under 600 V FINAL 0
Contractor Date DATE ]
400-1000 Amp.Under 600 V l(— ' �] ~
❑ I am exempt under Sec. (J V7 VALIDATION V
Over 1000 Amp.or Over 600 V FINAL W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY 0.
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F-141 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
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
- m�,4:
F-1 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors ``s1
s not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) )_i I(y ,x,39 2'3
and Professions Code).
CONSTRUCTION LENDING AGENCY ]] _
I hereby affirm that there is a construction lending agency for the n
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) & P
Civ.C.)
;LendPLAN CHECKING FEE c"jrg- -1--
Lender's
er's Name /-
PERMIT ISSUING FEE p2(� D
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
represe tatives J'this County o enter upon the above-mentioned property
for in
ction pose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE