HomeMy Public PortalAbout5933 AVON AVE_Electrical_5/19/1995_outlets WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) ���������®� ®� ���������� ������
76A663 �f
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.
co�pqoere (Sec.3800 Lab.. C.
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS.$13
0 `+ Certified'copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ .. _ $ LOCALITY
Certified co Is filed with the count building inspection 1&2-Family,Sq.Ft.
copy y g p NEAREST
department. Multi-family Sq.Ft. caoss ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR �
COMPENSATION INSURANCE Outlets:Rea_Light�Sw. j FIRM NAME
First 20 Ip 'MAIL
(This sectionTotal No. Additional S need not be completed if the work involved by the ADDRESS
permit'is for one hundred dollars(S100)or less.)
I certify that in the performance of the work fog which this permit CITY 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
!_��\j c ADDRESS
Data' a y 'Applicant—�� 7 RESIDENTIAL APPLIANCES NOT OVER 3 HP.
r I
NOTICE TO APPLICANT: If, after making this eficate 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 l ' I11 p''
provisions or this permit shall be deemed revoked. Power Apparatus&Large'Appliances APPLICANT N446 J.N 4�&45 r—
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 7fN
I hereby affirm fhat l am licensed under provisions of Chapter 9
Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY -2 Tel.No,Q�� � d
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.'
}
Over 50 to 100 InCI. LICENSE OR Class.REG.NUMBER
oo t7 Over 100 DISTRICT NO. PROCESSED JY^� O
License Number C14y Lic.Class ry ` '
Services,Swbd.,,MCC&Panelboards �� a j
(�' y'�� 4 �7 �j�ZD �7y - 0-399 Amp.Under 600 V FINAL Q
Contractor Date DATE �1 �
❑ 400-1000 Amp.Under 600 V — 14N
1 am exempt under Sec. VALIDATION V
Over 1000 Amp.or Over 600 V FINAL. a
B.&P.C.-for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A,.120V,Lighting or Recept. Z
1 To 10 Branch Circuits €
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits _`
Exemption'for Reg.Maint.Elect. 15A.20A,208V To 277V Lighting Br.Circuits. ec•:
' __. _ •.3+�a moi•
SINGLE FAMILY Temp. Power Pole&,Appurtenances
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit t� �.
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits” i,1i3 c+ `; ®corn.
I Code): t l _'•_.. �_=•_i_`-
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors rm
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D 3 j nrl
and Professions Code).
CONSTRUCTION LENDING AGENCY ;},'; t_, q—i I•F
T-17 UHJ
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) S.l�" _ Fi!'s +-
Civ.C.)
PLAN CHECKING FEE •
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE 4 33p-' �
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 yispection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ISIGNATURE OF PERMIT E ATE