HomeMy Public PortalAbout9050 ACASO DR_Electrical_2/20/1996 WORKER,:&COMPENSATION DECLARATION 20-0019 DPW(12-91X
76A663\-t- -- APPLICATION FOR ELECTRICAL PERMIT
I hereby-a,Tirm that I have a certificate of consent to self insure,
or a4certificate oV'Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
cgpy thereof(Sec. 3800 Lab. C.) .
Policy-go. Company FOR APPLICANT TO FILL IN JOB
ADDRESS !!//
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ y _ $ $ LOCALITY �
Certified copy is filed with the county building inspection 1 &2-Family,Sq. Ft. NEAREST
department. Multi-family Sq. Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Ir
OWNER OR
COMPENSATION INSURANCE Outlets:Rec. _11Z7 First 20 Light Sw. '�� ,` MAIL pc p FIRM NAME '110 b - /J
Lf
(This section need not be completed if the work involved by the Total NOi>CZ7 Additional ADDRESS !/ �/ /J D
permit is for one hundred dollars($100)or less.) YY
I certify that in the performance of the work for which this permit CITY ^ I 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 APPLICANT K
Total No. Additional
/���- ) ADDRESS
Date Applicant RESIDENTIAL AP PL NCE& VER 3 HP. e
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 f II force and effect. Over 10 to 50 Incl.
LICENSEClass.
S Over 50 t0 100 Incl. REG.NUMBB ER a
t�OU Over 100 DISTRICT NO. PF O� SED BY �,✓ Q
License Number Lia Class [}v V
Srvi es��y/r��SCC&PanelboardsFINAL
rl fi�yv�✓ �
Contractor Date �" � 3 ,"mp• Under 600 V v DATE r 0
El I am exempt under Se 400-1000 Amp, Under 600 V / H
Over 1000 Amp.or Over 600 V FINAL /v VALIDATION W
BY
B.&P.C.for this reaso BRANCH CIRCUIT FEES d
U)
Date: 15A,or 20A, 120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El
41 Or More Branch Circuits
Exemption for Reg.M int.Elect. : 15A,20A,208V To 277V Lighting Br.Circuits +}
S 1JGLE FAMILY Temp. Power Pole&AppurtenancesyAj�F/'y a
HOME OWNE -BUILDER DECLARATION ACCTA
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Sig33031a5sf�
�L3
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
1 ITEMS
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL �..�-_25 m 300
_
is not intended or offered for sale (Section 7044, Business Other(See Compleie Fee Schedule) l
and Professions Code). CHECK 125.80
CONSTRUCTION LENDING AGENCY CHANGE .00
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.) 0000-0001 2/20/91
Lender's Name `/' !��
\(%/V� C 1 4 d -- CJ-Ik ee PLAN CHECKING FEE 49i9 1 PM 12'.0")
PERMIT ISSUING FEF_ d
Lender's AddressDv
I certify that I have read this application and under penalty of p fury stat 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
A UREDO PERMITTEE DATE