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HomeMy Public PortalAbout9194 JAYLEE DR_Electrical_10/6/1993_outlets,fixtures WORKER'S COMPENSATION DECLARATION .20-0019 DPW(12-91) 76A663 APP LL-�CGs$TM FOR ELECTMA L PERNT - �f I hereby affirm that I have a certificate of consent to self insure, ora certificate of Worker's Compensation'Insurance,.or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV..` copy thereof(Sec.,3800 Lab, C.), Policy No. Company FOR APPLICANT TO FILL IN - JOB ,q I n�( P /�)/'.I C E D P ❑ . _.- - - -_ ADDRESS "L�-} �l J7( L Le - Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE i PLC �/` _ — $ $ LOCALITY .l EI�l s�L C �C 1 T./ Certified co .is filed with the count building ins ection 1&2-Family,Sq. Ft. _ PY y g P — NEAREST n ��y v 1 department: Multi-family Sq.Ft. CROSS ST. Roses M•�A� /� �I PE(2DR Residential Swimming Pools ASSESSOR r I Date - Applicant MAP BOOK S 3 G.. 'PAGE 0.15 - PARCEL ©2,7 CERTIFICATE OF EXEMPTION FROM WORKERS'- _ - OWNER OR !_ Outlets:Rec. Light SW. FIRM NAME �• v -M i - COMPENSATION INSURANCE L �� AVE',. First 20 MAIL - c.,p A his section need not be completed if the work involved by the Total No. Additional ADDRESS Qt02 :af✓'. 1�RDE DALt I`} `� permit is�for one hundred'dollars($100)or less.) 5RNj 1'A 3P)SL- certify that in {he performance of the work for whlcfi.this pe t CITY TeL Jo. is issued, 1.shall not employ any person in.any nner so to PLAN CHECK become sujecf to the Workers',Compensatio •La s. Lighting Fixtures First 20 APPLICANT 6, /t Total No. Additional ADDRESS q ID2 E• A(Z DC-fqllRLE A Date ^ : L Applicant nn�,tt 9No ,{ NOTICE T.O APPLICANT: 6f, after ma'ki ertificate of CITY Tel. . Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP., provision of the.Labor Code, you must forthwith comply with such PERMIT provisions or this'permit''shall be deemed-revoked,' Power Apparatus&Large Appliances. APPLICANT 0 W M `LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS; I.,hereby affirm'that I am licensed 'under provisions 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 Incl. LICENSE Class. } . REG.NUMBB ER a Over 100 ' DISTRICT NO. ' PR C ED BY O License Number. Lir Class V -" Services,Swbd.,MCC&Panelboarda � 0 399 Amp.Under 600 V FINAL Q, Contractor - _ .Dates -. ,.- DATE ❑ - 400' 1000 Am Under 600 V 7 /�/7 I am exempt under Sec. p ' I u( � VALIDATION V Over;1000 Amp.or Over 600 V FINAL W -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 SINGLE FAMILY Temp. Power Pole&Appurtenances y HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License'Law Sign with One Branch Circuit t tt for the following reason (Section 7031.5, Business and Professions 'Additional Sign Branch Circuits T��j� u`r t Code): ti_:u_r • ❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors 3 .am'" is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TATAL and Professions Code). 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 Lender's Name I I`s_;[_(g-j�;'!'s_j �;; 6/r; PERMIT ISSUING FEE a; Lender's Address I certify that I have read this applicatio and under penalty of purjury state TOTAL FEE that the above infor tion is correc I agree to comply with all County ordinances and In a s regulatin ectrical wiring,and hereby authorize representativ of his ounty to e r upon the above-mentioned property for inspec In ose SEE REVERSE FOR EXPLANATORY LANGUAGE l� - i! SIGNATURE 0F PE DATE