HomeMy Public PortalAbout9027 JAYLEE DR_Electrical_9/1/1993_outlets and light fixtures WORKER'S COMPENSATION DECLARATION 76A669 DPW(72-9t) API�"l���L!/tUT�®IIV' FOR ELECT CA PERMT'
76A663 wl LL odu �J
I hereby affirm that I have a certificate of consent to self insure,
or a•certificerte of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.13800 Lab.C.)
Policy No.' Company FOR APPLICANT TO FILL IN JOBAe
❑ Certified copy is he}eby furnished. New Residential Bldgs.&Pools NO. EACH FEE e ` }"(�YwC//
ADDRESS
. .. ,. — $ $ LOCALITY,- . �/77�
❑: Certified co Is filed with the count build inspection 1&2-Family,Sq.Ft.
copy Y g p t•'�r/�y�/�
department. Multi-family Sq.FL NEARESTCROSS ST.
DateApplicant Residential Swimming Pools ASSESSOR
_ MAP BOOK PAGE PARCEL
„r „CERTIFICATE_OF EXEMPTION FROM WORKERS' OWNER OR ,; Z �� /
Outlets:Rec. Light Sw. p� IRM NAME/'"L V
COMPENSATION INSURANCE G
I First 20
(This section need,not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS V V
I certify that in the performance of the work for which this permit CIT Tel.No.
is issued, I shall not employ any person in.any manner so as t0 PLAN CHECK
become;subject.to the Workers' Compensation Laws. Lighting Fixtures First 20 C APPLICANT
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.
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 Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby,affirm that I 'ain licensed under prov'isio'ns 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. Over 10 to 50 Incl
Over 50 to 100 Ind. LICENSE Class. }
REG.NUMBB ER d
License Number Lic.Class
Over 100 DISTRICT NO. PROCESSED BY O
V
Services,Swbd.,MCC&Panelboards C/o
0-399 Amp.Under 600 V FINAL 0
Contractor Date DATE,
ElI am exempt under Sec. 400-1000 Amp.Under 600 V
VALIDATION V
Over 1000 Amp.�or Over 600.V FINAL t a
B.&P.C.for this reasonBRANCH 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 . '
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.
for the following reason (Section 7031.5, Business and.Professions' Additional Sign Branch Circuits =T°-`-' '''
Co ):
i T[j"s:i
Misc.Conduits&Conductors �I�L ��,
1, as owner of the property,will do the work and the structure' '"-" ':'"" :'"'
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
And Professions Code). D (_ ! ri`�60
'!`'-_-
CONSTRUCTION LENDING AGENCY -•, ..
.. vl�l'il'�i.�f_ f 11 f
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) �3
Civ.C.)
PLAN CHECKING FEE
Lender's Name •D ks.p�,
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE (p
that the above information is correct. I agree to comply with all County
ordi ces and State laws regulating Electrical wiring,and hereby au rize
re reset es of this County to enter upon the above-mention property
I inspection poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
GNATURE OF PERMITTEE DATE