HomeMy Public PortalAbout9445 1/2 LAS TUNAS DR_Electrical_3/17/1993_Temp power pole WORKER'S COMPENSATION DECLARATION a 20:0019 DPW(12-9t)
76A663, APPLICATION FOR ELECTRICAL PERMIT
I.hereby affihm'that.l 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 tnereof Sec 3800 L b..C). �`.
Policy No. Company �: /• . AooREss .
0" Certified co is herb fiurnished. / 73 FOR O FILL IN'
EACH FEE' n
APPLICANT,,T _
copy Y New Residential Bldgs.&Pools" LOCALITY' �.
® Certified co is filed with the count building ins ection 1&2-Family,Sq. Ft.
copy Y 9 P NEAREST'
dep tment Iti family Sq.Ft.
Date side'tial Swimming Pools ASSESSOR
r �APPlicant ?MAP BOOK I PAGE PARCEL
CERTIFICAT OF EXEMPTION,FROM WORKERS' -Rec.—Light Sw
O tlets 6WN ..
COMPENSATION INSURANCE FIRM
First 20 MAIL NAM
(This section•need not be completed if the work involved by the ADDRESS
E
permit is for.one hundred dollars($100)of less4. .) Total No. Additional
I certify that in the performance of the work for which.this permit,
CITY
is issued, I shall notemployany per'so'n in any manner so as to PLAN CHEc � d
become subject-to the Workers' Compensation Laws. Lighting Fixtures First 20 . APPLICANT
Total No.' Additional _
_. ADDRESS
Date 'Applicant.,
RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO,APPLICANT: If, after making this .Certificate of. CITY No.
Exemption,.you should becomesubject to the Workers'..Compensation OTHER APPLIANCES NOT OVER 3 HP.
provlsions:of ttie'Labor Code,`you'must forthwith comply with such, APPLICANT
provisions or this permit shall'be deemed revoked. Power Apparatus&Large Appliances
'LICEN'SED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or•KVAR ADDRESS i
s
I hereby affirm.that 1'am licensed under provisions of'Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)of'Division 3 of the,Business,and CITY 4 Tel.N W
Professions Code, and,my license is in force and effect. Over 10 to 50 Incl.
Y LICENSE 6R Class. }
Over.50 to 100 Incl. REG.NUMBER
Over 100' DISTRICT NO. PRQC SED BX 0
License Number Lia Class��l _
Services,Swbd.,MCC&_Panelboards ��
0-399-Amp. Under 600 V FINAL 0
Contracto ?, / DATE H .
F-1
400-1000 Amp.Under 600 V r ' 0
1 am exempt under Sec.- VALIDA ON W
Over 1000 Amp.or Over 600 V' FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V, Lighting or Recept. Z
1 To 0 Branch Circuits
1 '
Signature 11 To 40 Branch Circuits-
41 Or More Branch Circuits 7 YJ
Exemption for Reg.Maint.'Elect. 15A,20A,208V To 277V Lighting Br.Circuits
c
SINGLE FAMILY Temp.Power Pole&Appurtenances,
HOME OWNER-BUILDER DECLARATION it
I hereby affirm'that I am exempt from the Contractor's License Law' Sign with One Branch Circuit it30_ 61.65
for the following reason (Section'7031.5, Business and Professions Additional Sign Branch Circuits g�^;�
Code): 1 ITEMS
iS
Misc.Conduits&Conductors _
I, as owner of the property,will do the work and the structure hITAL
is not intended or offered for sale (Section 7044,Business Other(See Complete Fee Schedule)
...61 5
and Professions Code). ® f4.•t-lLtCK'!
CONSTRUCTION LENDING AGENCY 4,Si li ji t�7 , lI
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)
Civ.C.) 'je l-13C-1 7/111
PLAN CHECKING FEE
Lender's Name - {:� :s 1
PERMIT ISSUING FEE ��
1 All
Lender's Address
6��n ka
I certify that I have read this application and under penalty of purjury state TOTAL FEE (p
that the above information is correct. 1 agree to comply with all County
ordinances and State laws regulating�ctrical wiring,and hereby authorize,
representat eye of this County to en Pon upon the above-mentioned property
for inspe oru'purposesr n SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE E ITTEE - DAT