HomeMy Public PortalAbout5426 ACACIA ST_Electrical_11/24/1992_outlets WORKER'S COMPENSATION DECLARATION 20 DPW(12 91) APPLICATION FOR' ELECTRICAL PERMIT
76A663
I hereby affirm that I have a certificate of consent to self Insure, 76A663
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 S6 2 fp fQ�/
I NO EACH FEE
Certified copy is hereby furnished New Residential Bldgs &Pools LOCALITY
4 1 &2-Family,Sq Ft — $ $ ���41�' ,9 y +
Certified copy is filed with the county building Inspection _ NEAREST
department Multifamily Sq Ft CROSS ST ZP,,010 wrg y
Date ' Applicant Residential Swimming Pools MAP BOOK I
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rei Light Sw � OWNER OR,
COMPENSATION INSURANCE FIRM NAME „Arlt (L Q
First 20 V
(This section need not be completed if the work involved by the ADDRESS Sy R-G�G
permit is for one hundred dollars($100)or less) Total No ti Additional
1 certify that in the peTformance'of the work for which this permit CITY Tel No,,, ` r
Is issued, I shall not employ any person in an"y manner so as to PLAN CHECK
become,sublect to the Workers'Compensation Laws Lighting Fixtures First 20 APPLICANT `
Total No` Additional ' v 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
p p Y Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked
LICENSEb 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 • a
LICENSE OR Class
' Over 50 to 100 Incl REG NUMBER 0
License Number LIC CIflSS Over 100 DISTRICT NO y PROCESSED BY V
` Services,Swbd,MCC&Panelboards
Contractor Date 0 399 Amp Under 600 V DATE V
❑ ' 400-1000 Amp Under 600 V 2s"�?,� •VALIDATION
I am exempt under Sec LV
Over 1000 Amp or Over 600 V FINAL _ 0-
B&P C for this reasonBRANCH CIRCUIT FEES BY co
•
Date 15A,or 20A,120V Lighting or Recept
Signature - 1 To 10 Branch Circuits ^ -
11 To 40 Branch Circuits
41 Or More Branch Circuits
-Exemption for Reg Maint Elect 15A,20A,208V To 277V Lighting Br Circuits _ s .,„ __ i _
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION
Branch Ci
Sign with One it
.rR -T Circuit
�-
I hereby affirm that I am exempt from the Contractor's License Law Sig �. �4r�}; s• �,,,,-• L` ■11g•. '
for the following reason(Section 7031 5, Business and Professions Additional Sign Branch Circuitssr�asr,
Code) - S .��• * _�- �.,y'_4 • _ � .�. �{� ; i'x ^ tile
I,as owner of the property,will do the work and the structure Misc Conduits&Conductors a ri Lr 1S ~
is not intended or offered for sale (Section 7044, Business Other .!Complete Fee Schedule) .., ' '` ` '` ==t�. t
and Professions Code) ',¢ i 411 AL
CONSTRUCTION LENDING AGENCY ” - ^;-°Tai• s _',`Y CHECK O ■55.n a _
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): (7 _ * `t7ta f ', i--5:'�" •U7►
Civ C) <
PLAN CHECKING FEE
Lenders Name :.+� _ _ t►�tAJV 1 ly/,24, 9,.
PERMIT ISSUING'FEE OL ^ , _ i i i i
Lender s Address . � ijj'1 j
1 certify that I have read this application and under penalty of purfury 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
representatives of this County to enter upon the above mentioned property '
for Ion p poses SEE REVERSE FOR EXPLANATORY LANGUAGE
NATURE OF PERMITTEE DATE