HomeMy Public PortalAbout5329 ZADELL AVE_Electrical_3/20/1996_ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(72-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT �1
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4 hereby affirm that I have a certificate of consent to self insure,
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.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
DDRESS2 �
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Certified copy Is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ NEAREST ` '
department. Multi-family Sq.Ft. CROSS ST. (.A ve
SSOR
Date Applicant Residential Swimming Pools MAP BOOK PAGE I.PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR / /� / ,yam/
Outlets:Rec.�Light�Sw. / FIRM NAME GRja,4O 6
COMPENSATION INSURANCE Al
First 20 MAIL a
(This section need not be completed if the work Involved by the Total No. Additional ADDRES 2> C—GZ- �L%
permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY -77WxZ T Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. r;, 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 �y _ ,� I 1
p y p y Power Apparatus&Large Appliances APPLICANT ! Z �t
provisions or this permit shall be deemed revoked.
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.
cl
0 I
0 to 5n .
Professions Code,and my license is in full force and effect. Over 1LICENSE ORClass. d
Over 50 to 100 Incl. REG.NUMBER
Over 100 DISTRICT NO. P ESSED BY O
License Number Lie.Class 1 O
Services,Swbd.,MCC&Panelboards p/ v ft61��L�� Q
Contractor Date 0-399 Amp.Under 600 V FDATE
INAL p/ O
r_1400-1000 Amp.Under 600 V ¢—l7 / W
I am exempt under Sec. VALIDATION
Over 1000 Amp.or Over 600 V FINAL IZ
B.&P.C.for this reason BRANCH CIRCUIT FEES BY ./ / — U)
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 2
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits6 a.
ACCTSINGLE FAMILY Temp.Power Pole&Appurtenances �7 a �
HOME OWNER-BUILDER DECLARATION 3303
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 1 ITEMS
Code):
TOTAL 47_3_
F1 1.as owner of the property,will do the work and the structure Misc.Conduits&Conductors 47„i17
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) CHECK
and Professions Code). , CHANGE .00
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) G' l`G�a�i / ����
Civ.C.) PLAN CHECKING FEE 5407 1 AN11=09
Lender's Name
PERMIT ISSUING FEE
Lender's Address �7 O
1 certify that I have read this application and under penalty of purjury state TOTAL FEE
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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
--NAT "
IG T RE OF PE WEE DATE