HomeMy Public PortalAbout9058 ACASO DR_Electrical_4/21/1992 WORKER'S COMPENSATION DECLARATION 9DPW 9/89
76A663 APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm that I 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 JOBF-1
ADDRESS
Certified co is hereb furnished. EACH NO. FEE
PY Y � New Residential Bldgs.&Pools LOCALITY
❑ Certified co is filed with the count buildinginspection 1&2-Family,Sq.Ft. $ — $
y p Y q CROS,3T.
department. Multi-family S Ft. Lf��
Date Applicant Residential Swimming Pools ASSESSOR
�-y MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec0 Light Sw. / FlRM NAOR
ME /' /� G�V
COMPENSATION INSURANCE �.cn�
First 20 'MAIL �/
(This section need not be completed if the work involved by the Total No.r Additional 3 ADDRESS O� p ��
permit is for one hundred dollars($100)or less.)
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20• APPLICANT �,,. IF
;g!5_
g!5 5i Z)
Total No. Additional
ADDRESS f/
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS /, '
NOTICE TO APPLICANT: If, after making this Certificate of 2
/�� CITY/Jy�� l ��/�-Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
P Y P Y APPLICANT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. U
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
Power Apparatus&Large Appliances REG.NUMBER class.
License Number Lic.Class Size&Type HP,KW,KVA,Or KVAR DISTRICT NO. PRO ED BY
Up to 3 Incl. o-p W
�I
Over 3 to 10 Incl. FINAL IL
ContractorDate DATE CO
Over 10 to 50 Incl. ^� 7 Z
r_1I am exempt under Sec. Over 50 to 100 Incl. `(/Q' Zi VALIDATION
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201 -1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances ;
HOME OWNER-BUILDER DECLARATION ^�'_•'•.,f ='-
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ry." _f
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits "
Code):
t
d
&C
it
d
Conus Conductors
_..., ..
I, as owner of the property,will do the work and the structure Misc. -•�;f•z(� �•e.x,��•- K� M _ ,,-
1k is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) - -• ' '
and Professions Code). , ;< s :•i> r C;
CONSTRUCTION LENDING AGENCY
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.) :•,r�ri .t s
PLAN CHECKING FEE '-
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE 490 .
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
properA for in ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
14
a1 Z
1 T E OF APPLICANT OR AGENT - DATE