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WORKER S COMPENSATION DECLARATION 20 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that I have a certificate of consent to self Insure 76A663
or a 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) z
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished l Bldgs &Pools NO EACH FEE
❑ New Residentiags _ $ $ LOCALITY G — C�Y
Certified co is filed with the count building inspection 1&2 Family Sq Ft
PY Y 9 P NEAREST , t
department Multifamily Sq Ft CROSS ST (�G— y
Date Applicant « Residential Swimming Pools t ASSESSOR
O
PAGE 006PARCEL
OWNER OR �jj,�%7�/f
CERTIFICATE OF EXEMPTION FROM WORKERS z 1 r(J .2
COMPENSATION INSURANCE Outle s Rec _Light J Sw � rj� // FIRM NAME I �
First io / d (O MAIL
(This section need not be completed if the work involved by the Total No _� Additional ADDRESS
permit is for one hundred dollars(5100)or less) syy�
I certify that in the performance of the work for which this permit CITY Z?r! Tel No
is Issued I shall not employ any person in any manner so as to p Q
become subject to the Workers Compensation Laws Lighting Fixtures First 20 PLAN CHECK
o p APPLICANT
Total No Additional
ADDRESS
Date �n —a� i `�` Applicant I E IAL AP IANCES NOT OVER 3 HP
NOTICE TO APPLICANT If aftgr' make g this CertificaI of CITY G� C Tel No Z�J-ff/z
Exemption you should become subject to the Workers Compen of
OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply wit such APPLICANT
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances
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 licens-is in full force and effect Over 10 to 50 Incl >_LICENSE OR Class ll
Over 50 t0 100 Incl REG NUMBER O
Over 100 DISTRICT NO ESSED BY U
License Number Lic Class
Services Swbd MCC&Panelboards cc
Contractor Date 0 399 Amp Under 600 V DATE FINAL O
r-1I am exempt under Sec 400 1000 Amp Under 600V Z—� VALIDATION W
Over 1000 Amp or Over 600 V FINAL d
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
El
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 Sign with One Branch Circuit v
I hereby affirm that I am exempt from the Contractors License Law , cti ---
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits
Code) TT
(71
Misc Conduits&Conductors
�l I 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) TI t I HL. 35
and Professions Code) £ —_
CONSTRUCTION LENDING AGENCY LL11 s i
I hereby affirm that there is a construction lending agency for the tH I
performance of the work for which this permit is Issued (Sec 3097 PERMIT FEE (Sub Total) / 5
Civ C) _
PLAN CHECKING FEE tEl� t_i�trii_; _7 y y
Lender s Name / —
PERMIT ISSUING FEE f_cr,,.
Lender s Address
I certify that I have read this application and under penalty of purlury state TOTAL FEE _ o
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 inspe pur se /— SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIPkATURE OFPtRIAITTEE DATE