HomeMy Public PortalAbout10538 DANBURY ST_Electrical_6/25/1993_outlets WORKER'S
haveCOMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FQ. LECTR�CAL PERMIT
0-663
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.6-11PUBLIC WORKS BUILDING AND SAFETY DIV. -
copy thereat(Sec.3800 Lab. C.),- 1 1,Ir
FOR APPLICANT TO FILL IN JOB /f%�j OM
Policy No. Company 0 JCJ
AOORESS
'Certified copy is hereby furnished. New Residential Binge.&Pools NO, EACH FEE LOCALITY C n
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. — $ $ T`M r '
department. MultifamilySq.Ft. cR0S5 5T. W, +V
Date - Applicant Residential Swimming Pools ASSESSOR
_ ���JJ MAP BOOK
CERTIFICATE OF EXEMPTION FROM WORKERS' .. Outlets:Rec.yL Light LS—Sw. OWNER OR '
COMPENSATION INSURANCE 2 �,.90 3 O FIRM NAME C� ^ 10 1,111 A
(This section need not be completed if the work.involved by the First 21) o J MAIL
permit is for one hundred dollars(5700)or less.) Total No. Additional z ADDRESS E- 112
I certify that in the performance'of the workforwhich this permit CITY Te. o.3s�
is issued, I shall not employ any person in any manner so as toPLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixture First 20 APPLICANT
Total No. Additional
" ADDRESS
Data Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT:-If, after making this Certificate of CITY Tel.No.
Exemption,youshould 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 Siz_e.&Type HP,KW, KVA,or KVAR ADDRESS _
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 101ncl.
(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. Over 10 to 50 Incl.
LICENSE OR Class.
Over 50 to 100 Incl. REG.NUMBER 4.
Over 100 DISTRICT NO. P SED BV Q
License Number LIC.Class �/
Services,SwbC,MCC&Panelboards
Contractor Date 0-399 Amp. Under 600 V DATE _ 0
1 am exempt under Sec. 400- 1000 Amp.Under 600 V +7 Z ~
❑ J'2 J— VALIDATION U
Over 1000 Amp.or Over 600 VW
.&
-BP:C.for this reason - BY
AL d
BRANCH CIRCUIT FEES U)
Date: 15A,or 20A, 120V,Lighting or Recent. Z
- - - - - 1 To 10 Branch Circuits
Signature _ 1 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Rag.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
'I
SINGLE FAMILY Temp, Power Pole&Appurtenances _ �Ppt�++T -
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit A1.1 i .i
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 =00 7lCode): ,
5 ITEMS I, as owner of the property,will do the work and the structure Misc.Conduits 8 Conductors .. ,. 1 1Tt1!_ i
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 71? e 65
and Professions Code). - LL
CONSTRUCTION LENDING AGENCY CHECK 9.Ci5'
I hereby affirm that there is a construction lending agency for the t_.HF'}NGE .03
performance of the work for which this permit is issued (Sec: 3097, PERMIT FEE (Sub-Total)
Civ.C.) -
- PLAN CHECKING FEE 2S DDDCI'DDD1 6/M 4?b
Lender's Name
PERMIT ISSUING FEE 0412 1 PN E=5+3
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE 713 `(g
that the above information is correct. I agree to comply with all County
ordinances and State laws regll[alpQ Electrical wiring,and hereby authorize
representatives of this County to pan the above-mentioned property
for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE
J
SIGNATURE OF—PERM TTEE �• DATE