HomeMy Public PortalAbout5947 AVON AVE_Electrical_3/1/1995_outlets WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LJ
1,hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker'eCompensati'on Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sea 3800 Lab. C.)
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Policy No. « Company FOR APPLICANT TO FILL IN JOB -
ADDRESS l"
NO. EACH FEE
Certified copy is hereby furnished. New Residential Bldgs.&Pools _ $ $ LOCALITY
❑ Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft.
PY Y 9 P
department. Multi-family Sq.Ft. NEARESTCROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
( MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec..�L Light�S, OIRM NAME OR
]
COMPENSATION INSURANCE
First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional D ADDRESS �r�l'7 1✓aY+^
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY �� Tel.
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 PPLICANT
Total No. Additional
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.
PERMIT
provisions of the Labor Code, you must forthwith comply with such Power Apparatus&Large Appliances APPLICANT
provisions or this permit shalt be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 1— Over 3 to 10 Incl. / a�
(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 t0 100 Incl. REG.NUMBER a
Over 100 DISTRICT NO. P ED BY Q
License Number Lic.Class V
Services,Swbd.,MCC&Panelboards
Contractor Date 0-399 Amp.Under 600 V DATE O
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V H
VALIDATION V
Over 1000 Amp.or Over 600 V FINAL W
B.&P.C.for this reason* BRANCH CIRCUIT FEES CD
BY
Date: 1¢ADk or 20A, 20V,Lighting or Recept. �O Z
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
SINGLE FAMILY Temp.Power Pole&Appurtenances »___ - '``t
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit tis
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
Code)
❑ 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)
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the :-i;1} ;r "CII.,
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) _ ._ 3 ;.=s -• -
Civ.C.) ? "1
PLAN CHECKING FEE -� a
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
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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
\IGNA URE OF PERMITTEE DATE-