HomeMy Public PortalAbout9635 LAS TUNAS DR_Electrical_8/3/1994_AMPS WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91)
I her4y affirm that I have a certificate of consent to self insure,
76A663 APPLICATION FOR ELECTRICAL PERMIT LLLJJJ
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
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY-1,0t
❑ 1$2-Family,Sq.Ft. — $ $
Certified copy is filed with the county building inspection _ NEAREST
department. Multi-family Sq.Ft. CROSS ST. A
Date Applicant Residential Swimming Pools ASSESSOR
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' , I Outlets:Rec._Light Sw. OWN NAME !�r p
COMPENSATION INSURANCE First 20
This section need not be completed If the work Involved b the MAIL 1(Z"
permit is for one hundred dollars(8100)or less.) y Total No. Additional ADDRESS C (nft�YA
I certify that in the performance of the work for which this permit CITY G A-�O Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compen tion LaKs. Lighting Fixtures First 20 APPLICANT
oil.�i4i�Nlrroh Total No. Additional
ADDRESS
Date ^3'-Ly Applican4ytmyJ 6DX.24•tiL:,%• 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
p p y Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 19724
1 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. RIEG.NUMBER CENSE OR Clare' }
Over 100 DISTRICT NO. P�pCFsED BY 0
License Number 9010 Lic.Class C_%) �Q �j C� a
Services,Swbd.,MCC&Panelboards o �iL fY
,p� • ^� 0-399 Amp.Under 600 V DTE ,�r�'��
L 0
ContractorYtNY—P+A C far Data Y / 0
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V III
Over 1000 Amp.or Over 600 V VALIDATION �
FINAL 0.
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date:
15A,or 20A,120V,Lighting or Recept. D Z
1 To.10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ _ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,MA,208V To 277V Lighting Br.Circuits 2
SINGLE FAMILY Temp.Power Pole&Appurtenances r.�. l:
HOME OWNER-BUILDER DECLARATION AC 1
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law �r n
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 3.x03 86.211
Code): 3303
.50
❑ I,as owner of the property,will do the work and the structure I Misc.Conduits&Conductors 6 _ ;
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) +{ =TET:
and Professions Code). Poo. TOTAL 86 _7[33
CONSTRUCTION LENDING AGENCY CHECK K 36a70
1 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) CHANGE ,_10
Civ.C.)
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE 0000-0f,1101vI 3/9.4
Lender's Address ryO 6,s 9 1 A � 8:39
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 purpo ' SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF P.ERMI EE DATE