HomeMy Public PortalAbout10554 DANBURY ST_Electrical_5/6/1993_power apparatus _WORKER'Shave COMPENSATION DECLARATION 260019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm that I have a certificate of consent to self insure, 6A663
or a certififf((te Of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy therQa/(Sec. 3800 Lab. C. /
Policy
NO man y FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified Copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALI
Certified copy is filed with the county bIdingpp'''���'nspe fir 2-Family,Sq.Ft. $ $ NEAREST
r tlepa.rtm n / Multifamily S CROSS ST.
Date Appl,ca 'AGq< Residential Swimmimm ing POO a ASSESSOR
PAGE PARCEL
CERTIFICATE OF EX ON FROM WORKERS' Outlets:Rec._Light_Sw. OWN R OR
GO PEN IONINSURANCE
(This.section need not be completed if the work involved by the FirstME
MAIL
permit is for one hundred dollars($100)or less.) Total Na, Additional AODREsS ¢JR/
1 certify that in the performance of the work for which this permit CITY
Is issued, I Shall not employ any person In any manner s0 as to ,PLAN CHECK
become subject to.the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HR
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel Ni
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 APPPERMIT LICA rl/
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances /
LICENSED CONTRACTORS DECLARATION Size&Type HE,KW,I or IADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 101 loci.(commencing with Section 7000) of Division 3 of the Business and CITY r"l Tel No. _
Professions Code,and my license is in full force and effect. Over 10 to 50 cal. E5Q >_LICENSE OR Clas
Over 50 to 100 Incl REG.NUMBER - d
Over 100 DISTRICT NO' P OC SED BY O
License Number Lia Class �' [�' 0
(/ Services,Swbd..MCC&Panelboards 0 0
Contra o ate / T 0-399 Amp. Under 600 V FINAL 0
❑ exempt under Sec. 400-1000 Amp. Under 600 V f
VALIDATION U
Over 1000 Amp.Or Over 600 V FINAL d
B.&P.C.for This reason BRANCH CIRCUIT FEES BY W
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits • -
❑. - 41 Or More n, Branch Circuits a
Exemption for Reg. MaiElect. 15A,20A.208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
f 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 -{I_
Code): TTE(1'_
1T
❑ 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors - �-§
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 43 ® 80
and Professions Code). Oji
t.il n 'tom.-.v
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.)
PLAN CHECKING FEE 0000-0001 1 6/9--
Lender's
!`SLender's Name �rrrG 1 jjt'j��,;41j
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE 3,
that the above information is correct. I agree to comply with all County
ordinances d to a laws egulating Electrical wi% ntl her by authorize
represent ve o his C u y t enter a above-men oned ropeny
P
'pose SEE REVERSE FOR EXPLANATORY LANGUAGE
sIG TUBE OF PERMITTEE DATE