HomeMy Public PortalAbout5420 ACACIA ST_Electrical_11/9/1992_ outlets • WORKER'S COMPENSATION DECLARATION 726A6fi3 DPW(12 91) ' APPLICATION FOR ELECTRICAL PERMIT 11
I hereby affirm that I havb a certificate of consent to self Insure,
or a cer}rticate of Workers Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy t6ereof,(Sec,3800 Lab#C)
Policy NO Company FOR APPLICANT TO FILL IN JOB
ADDRESS
❑' Certified copy is hereby furnished NO EACH FEE
%. - I, New Residential Bldgs 4 Pools _ LOCALITY
❑ Certified copy is filed with the county building Inspection 1 &2-Family,Sq Ft $ $
department _ t Multifamily Sq Ft - NEARE ST
Date '% Applicant' Residential Swimming Pools, ;t ASSESSOR
MAP BOOK PAGE -.vPARCEL-Z2
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec 7-2-Light — ,Sw ' OWN NAME �(� I
COMPENSATION
INSURANCE ,,
(This section need not be completed if the work Involved by the ,��..--s�yy.////�� First 20 ADDRESS
permit is for one hundred dollars($100)or less') Total No sem_ Additional
444:6 a I certify that In the performance of the work for which this permit ' CITY SjT , Tel No "
is issued,I shall not employ any person in any manner Was to ' PLAN CHECK
become subject to the Workers Compensation Laws ,Lighting Fixtures First 20 APPLICANT
Total No ZR: 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 J Over 10 to 50 Incl }
LICENSE OR
y +. Over 50 to 100 Incl REG NUMBER Class
Over 100- "• d
License Number Lic Class DISTRICT NO P C ED BY V
Services,Swbd, CCC&P n I oa •��
Contractor Date 0 39Amp Under 60 V DATE 0
❑ ` Z 0
400-1000 Amp Under 600 V
I am exempt under Sec VALIDATION •V
„ Over 1000 Amp or Over 600 V FINAL LLI
d
-B&P C for this reason BY
BRANCH CIRCUIT FEES
Date 15A,or 20A 120V,Lighting or Recept - - Z_
1 To 10 Branch Circuits
Signature , - -- 11 To 40 Branch Circuits -
41 Or More
❑ Exemption for Reg Mairit Elect ` 15A,20A,20 VV To 277V Lighting Branch Circuitsuits � 152.3.'1��°j!
SINGLE FAMILY Temp Power Pole&Appurtenances , _td
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -' I-ITE t4
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 TOTAL 152.37
Code) r
37
I,as owner of the property;will do the work and the structure Misc Conduits&Conductors ,�r CHECK� 152°-r`
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ® �HAN� , It
and Professions Code) __ _ _ ..
CONSTRUCTION LENDING AGENCY ���y
I hereby affirm that there Is a construction lending agency for the r v 13000-13001 11!' 9/9+
performance of the work for which this permit is Issued (Sec 3097, PERMIT FEE (Sub-Total) a 67693 1 AM ■--
PLAN CHECKING FEE -
_i
Lender's Name
Lender's AddrPERMIT ISSUING FEE
ess • �w• "
I certify that I have read this application and under penalty of purjury state TOTAL FEE 0(
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 inspection purpos s SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE