HomeMy Public PortalAbout9058 ACASO DR_Electrical_5/20/1992 WORKER'S COMPENSATION DECLARATION 9 DPW 9/69
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 JOB yy
ADDRESS
Certified co is hereby furnished. EACH NO. FEE
PY Y New Residential Bldgs.&Pools LOCALITY
$Ft $
Sq. . —
Certified copy is filed with the county building inspection 1 &2-Family, _ NEAREST
department. Multi-family Sq.Ft. CROSS S7. a
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR
FIRM NAME RC]�Q ct {.t Cs
COMPENSATION INSURANCE
First 20 MAIL
(This section need not be completed if the work involved by the ADDRESS
permit is for one hundred dollars($100)or less.) Total No. Additional 0.r SID
I certify that in the performance of the work for which this permit CITY 121 R
Tel.No.
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
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY ` al- Tel.N
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
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. C 1
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR IM
Power Apparatus&Large Appliances REG.NUMBER class.
License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY U
Up to 3 Incl. W
Over 3 to 10 Incl. FINAL C'
Contractor Date DATE (1)
❑ Over 10 to 50 Incl. 2�,,rr�� Z
I am exempt under Sec. Over 50 to 100 Incl. `!�/— ]/� VALIDATION
B.&P.C.for this reason Over 100 FINAL
� BY
Services,Swbd. MCC&Panelboards
Date: it
0- 00 Amp. Under 600 V ' i _ d
Signature 201 -1000 Amp.Under 600 V —J
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION '•..4,) "
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 '„`i a','
Code):
Lam( 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors1
/ 1 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) iand Professions Code). ® �• h
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the .r:Tt»
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
..,._.._ ...sem_. �=f.�:�:: •.._,
Lender's Name
PERMIT ISSUING FEE �/� : 40
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
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
pro er for in pection purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
e1 '
IGNATURE OF AP LICANT 08 If D E