HomeMy Public PortalAbout9560BISBY ST_Electrical (7) �� ORkFA'3 COMPENSATION DECI�4RAT}UN DPS(12-91) APPLICATION FOR ELECTRICAL PERMIT
I horebyfaN_Irm that I have a Gertlflcatq of consent to self Insure, V +
or a oertinoate of Worker's Compensation Insurance, or a certlfled COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Seo. 3800 Lab.C.)
Policy No. Company PUR APPUCAN r TO FILL IN JOB
AL7ORE1� O $ S
❑ CertfM1ed copy b hereby furnished. NowReeklentlal Bkige.S Pools NO. EACH FEE
—1 1 &2-FamDi LOCALITY❑ y, q. LOCALITY Ttr'1 /1 ( O
tfM1ed CerDopy Is PI-ad with the county building Inepectiort Ft — �gT
departrnent. Multi-family Sq.Ft OAOBe BT.
Date Appiloant Flookontlal Swamming Pools ASSESSOR
MAP BOOK PA9E PAFK:✓3
CEFTIFICATE OF EXEMPTION FROM WORKERS' outbts:Rec. Light Sw. �NAME, SW PO R N
&S1 PAI
COMPENSATE ON INSURANCI
(this Motion need not be ooAdditio
Total Nonal
mpleted 11 the work Involved by the dd 20
permit Is for one hundred dollars(9100)or leas.) . AX00
I certify that In the performance of the work for whlch thle permit CITY Tt t4
Is Issued, I shall not employ any person In any manner so as,to PLAN pill(
become subject to the Workers'Compensation Lava. Llghting Flxturee Rrfft 20 APPLICANT
Total No. Addttional ADDRESS
DadeApplbartt RESID[]MAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making thle Certificate of CITY TOL Nb
Exemptlon,you should blooms subject to thb Workers' Compensatlon OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such P �>
provielona or this permit shall be deemed revoked. Power Apperahm S Large'�ppllancee
LICENSED CONTRACTORS DECLARLAT}ON Stre 8 Type HP,KW,KVA or KVAA ADDRESS
I hereby affirm that I am Iloeneed under provlelons of Chapter 8 Over 3 to 10 Ind.
40
(commencing with Section 7000) of Dlvielon 3 of the Business and CITY T'L
Professlons Code, and my Ilcense Is In full foroe and effect. Over 10 to 60 Ind. L)CENSE OR
Over 50 to 100 Ind. NUMBER Ott- d
license Number Lk.Uses Over 100 Dt8TR1CT NO. y�-w-
aY
Servbee,Swbd.,MCC a Panelboerda DO a
f bntrnctor Data 0-3BB Amp.Under 800 V DATE
400-1000 Amp.Under 800 V 2
❑ I am exempt undor Seo VALIDATION W
Over 1000 Amp.or Over 800 V FINAL
B.SP.C.for this reason BRANCH CIRCUIT FEES (�
Date: 16A,or 20A,12OV,Ughbng or wept- Z
1 To 10 Branch Ciroufts
Signature 11 To 40 Branch Cicufts
41 Or
F-1Exemption for Rep.Malnt Elect. 16A,20A1 20BV To 277V L Mon Ctraite
Tt:ng Br.
2
HOME SINGLE EILY Temp.Power Pole S Appurtenencee
OWNF--BUILDERECLARATION AULT
.T — -
I hereby affirm that I am exempt from the Contractor's Lldonee Law Sign with One Branch Clrcult _ ;�y17 41.38�
for the following reason (Sectlon 7031.6, Business and Professions Addtlonel SFgn Branch CIrcufta 330 Tia 76ti.r
Code)91:
I, as owner of the property,will do the work and the structure Wac.Condults 8 CwAUctm -TOTAL
_ _ i
Is not Intended or offered for sale ($ectlon 7044, Business Other(See Complete Fee Schedule)' 1 tJTti 1
and Professions Code).
BECK--- - 41.98
GONS-MUCT10N LENDING AGENCY "
.00I hereby arm that there le a conetructlon lending agency for the
affirm
performance of the work for which this permit Is Issued (Soo. 3087, PERMrr FEE (Sub-Total)
Cly. C.)
PLAN CHECKING FEE 000&-MO1 1/21/93
L.endere Name PERMrr ISSUING FEE --77vA '1 PM 12:17
Lender's Address
I certify that I have read thio eppkatfon and under penalty of pudury state TOTAL FEE
that the above Information Ia oDn ct I agree to compty with ag County
ordIrian coo and State laws regulaiing Eleotr4cal wWrig,and hereby authortxe
representatfvee of thle County to enter upon tha above-montloned property
for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANQUAGIE
pDn I-y1-90
WwAlU FE OP DATE