HomeMy Public PortalAbout9552BISBY ST_Electrical WORKER'S COMPENSATION DECLAAATk>tJ zo-0o,°°P"(12-91) APPLICATION FOR ELECTRICAL PERMIT
W 76A663
I hereby atflrm that I have n certificate of consent ?b 8131f Incurs,
or a certificate of Worker's Compenaatlon Insursnoe, or a certlned COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLIGIHT TO RLL IN AJOB
S. '70-T-;75— z
5
❑ CerttW copy la hereby tumlahed. New Raaldonft Bldgs.8 Pods NO. EACH FEE
LOCALITY
❑ 1 S 2-Family,Sq.Ft — 1 i
dapared copy le sled with tM county bu6ding tnapeotion CRK)SSNEAREST
depar[rnent Alulti-famlry Sq.Ft cao88 sr. ` L
Date Appllcarrt Reeidentlal SwlmrNrig Pools ASSESSORMAPBOOKPABi/
P
OWN
OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:P.. Light Sw. �
COMPENSATION INSURANCE FretMA
NAU
(t'hlo section,need not be completed H the work Invotved by the . ddiAddl 20tional jDDRESS L 5'
perrhlt Is tot one hundred dollars(111111 DO)or lese.) Total No
I certify that In the performance of the 1Vork for which this permit CITY /
Is Issued, I shall not employ any person In any manner to as to PLAN CHECK 10
beoome subject to the Workers' Compensation Laws. Lighting FUduree ret 20 AppiJCANT
Total No.� Addtdonal 0
ADDRESS
Data Appikcant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of IT TOL No.
Exemption,you should beoome subject to the Workers' Compermuon OTHER APpL1ANCE3 NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such P�
provisions or this permit shall be deemed revoked. Power Appar"8 Large A'ppllances
LICENSED CONTRACTORS DECLARATION Size S Type HP,KW,KVA,or KVAR ADDRESS
I hereby oVIrm that I am Ilcehaed under provisions of Chapter B Over 3 to 10 Ind.
(commencing with Section 7000) of Division 3 of the Business and CITY TOL N0
Professions Code, and my license Is In full force and effect. Over 10 to 50 Ind• r^ r OR Cues. a
Over 50 to 100 Ind. REO.NUMBER
Over 100 DISTRICT NO. BY
License Number LIc.Ctese
Swvlcm,Swbd.,MCC a Ponelbowde e d
contractor Date 0-399 Amp.Under 600 VDATE
FINAL O
❑ I am exempt under Sec. 400-1000 Amp.Under 800 V VALIDATION UJ
Over 1000 Amp.or Over 600 V FPlA1 CL
B.SP.C.for this reeaon BRANCH CIRCUIT FEES ErY rj)
Date:. 15A,or 213A, 120V,Lighting or ReoepL ,
Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Clroufb
41 Or More Branch Clrcutts
❑ Exemption for Reg.MaInt:Elect 154 264 206V To 277V Br.Crouls 2
SINGLE FAMILY Temp.Power Pole S AppurteAarwee
HOME OWNER-BUILDER DECLARATIONf' JL
I hereby affirm that I am exempt from the Contractor's License Law SIln'�One Branch Clroult ACC •ir
for the following reason (Section 7031.5, Business and Professions Addfdohal Sign Branch C4=fta 33W7.al
1 i I
I, ae owner of the property,will do the work and the atrucWre Misc.Condom 8 Conductero TEM
le not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , TOTAL 37 - 60
Code:
and Professions Code). - r
CONSTRUCTION LENDING AGENCY 67.60
L�R 17+�L
I hereby affirm that there Is a construction lending agency for the L .00
performance of the work for which this permit Is Issued (Seo. 3097, PERMrr FEE (Sub-Total)
CN. C.)
PLAN CHECKING FEE // 00 —0371 10061/94
L.endWa Name PERMrr ISSUING FjEE 7478 1 AM 11:12
Lenders Address
I certify that I have read ttda appllcadm and under penalty of purjury stain TOTAL FEE
that the above Infomudion le correct I agree to comply with all County
ordinances and State laws regulating Elect icatwlrtng,and hereby aud"tze
repreeentaf}vee of ffi my to enter upon the above-mentioned property
for Inspection p SEE REVERSE FOR EXPLANATORY LANGUAGE