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HomeMy Public PortalAbout9635 LAS TUNAS DR_Electrical_1/11/1996_TEMP POWER POLE W ORKER'S COMPENSATION DECLARATION 1200.060119 DPW(12-91) I I hereby affirm that I have a certificate of consent to self Insure, APPLICATION FOR ELECTRICAL PERMIT or a certificate of Worker's Compensation Insurance, or a certified I COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab,C.) PoID I Company G 4 FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE / ,�� $ $ LOCALITY (�� ❑ Certified copy is filed with Zhecount section 1 &2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. Date �- plicResidential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' I Outlets:Rec._Light Sw.. OWNER OR • COMPENSATION INSURANCE I FIRM NAME First C..�! (This section need not be completed If the work Involved by the Total No. Additional ADDRES permit Is for one hundred dollars($700)or less.) I certify that in the performance of the work for which this permit (CITY �a F 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. Additional (ADDRESS e 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 pD� p p y fJ�G4� provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl: .e© `7 (commencing with Section 7000) of Division 3 of the Business and ' CITY & 6�5 Tel. Professions Code,and my license is.in full force and effect: Over 10 to 50 incl. LICENSE OR Over 50 to 100 Incl. REG.NUMBER •� C �L Class. IL �fOver 100 DISTRICT NO. EBBED BY V G License Number Lic.Class % •' ! Services,Swbd.,MCC&Panelboards v _ f� 0-399 Amp.Under 600 V DAFINTE v ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V V VALIDATION V Over 1000 Amp.or Over 600 V FINAL 01 W CL BAP.C.for this reason BRANCH CIRCUIT FEES BY U) Date: 15A,or 20A,12OV,Lighting or Recept. Z 1 To 10 Branch-Circuits I Signature 11 To 40 Branch Circuits �• r_141 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances A/+. s,• HOME OWNER-BUILDER DECLARATION ACCTn4 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law � —,-, for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits x,303 78020 Code): ' 1 ITE HS ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). ® CHECK 78.20 CONSTRUCTION LENDING AGENCY CHANGE .00 I hereby affirm that there is a construction lending agency for the C performance of the work for which this permit is issued(Sec. 3097„ PERMIT FEE (Sub-Total) Civ.C.) • PLAN CHECKING FEE 0000-0001 1/11/96 Lender's Name 4223 1 AM10-030 PERMIT ISSUING FEE Lender's Address TOTAL FEE I certify that I have read this application and under penalty of purjury state 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 fo�- ion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE ��--,� SIGNATURE OF PERMITTEE DATE