HomeMy Public PortalAbout5002 BARTLETT AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 25m1G DPW(12-01)
I Hera APPLICATION FOR ELECTRICAL PERMIT
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qy-afffrm�that I have a certificate of consent to self Insure,
or a artlflaate 4 Workpr's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Selo Lab.C.)
Policy No0 SLG /// COm cam�+/ //�— Yl`S/ FOR APPUCAxr TO PILL IN ZREBl AM
Y
❑ CerM*d copy M hereby tumWbe New Reeldential Bkige ✓4 NO. EACH FEE
❑ 1 &2-Femlly,Sq.Ft — S L
CertfM1ed Dopy le}fled with the canty,bufWIN _
departrnent Muk1-family Sq.Ft �ST.
el Swfmming Poofa ASSES"
Data Apel MAP BOOK �(p PAGE O PAFCa
FICATE OF DEM WORKERS' Qutieta: Light OWNER OR
COMPENSAnONI URANCE
(fhls section need not I?s completed If the work Involved by the VNo.
Flrat �
permit Is for one hundred dollars($100)or lees.) Total �rdo� ADDRESS yI oertlfy that In the peHormance of the work for which this permit CITY teLIs Issued, I shall not employ any person In any manner so as to PLAN GHE&become subject to the.WgCkers' Compensatlon Laws. UgMng Flrat APP aur
To,al
ADDRESS
Date Applkarrt
NOTIC-E TO APPLICANT: If, after making thlp Certificate of d 3�' CITY Tet No-
Exemptlon,you should become subject to the W«kerb' Compensation OTHER APP S NOT 3 HP.
provieldns of the Labor Codg, you must forthwith comply with such PERPower Apparatus encs• APPLICANT
provlelons or this permit @hell be deemed revoked.
LICENSED CONTRACTORS DECLARATION Stn S Type HP, A «KVAR ADDRESS D
I hereby affirm that I am Ilceneed under provisions of Chapter B 3 to 10 Ind. JF
(commenoing with Seotlon 7000) of Dlvislon 3 of the Business and CITY b TeL No.
Professions Code,and my Iloense Is In full f«ce and effect. 10 to 50 Ind.
60 to 100 Ind. =M� O1■■■- d
Ucenee Number41:70-7—LIC.Qla" f' o ,00 ot8lxncT ND. ED BY
Servtcee,Swbd., S elboerde by
Date .-� 0- P.U 6,400 V Amp.U 80D V Fa I G� p
❑ Ism.xam urd., eo. over ' Amp « t3op V �—` 1 ` ly��nON W
B.AP.C.for thle reason BRANCH C CUF FEES a-
lly
ata: 16A « gtrtl
,2ov,LJng or ACCT i z
1 To 10 B Clrouite ■T
r 11 To 40 CIrtub41 733.
i p,
❑ Exemption Reg. Chutts
Mehrt Elect 15& 2018V To 27N L Mor Br.Cku� �` �13■�'
_ EETI'�
A11 IT
HOME OWNER43UILDERSINGLE ILY DECLARATION TOTAL
Power Pde S Appurtenances TOTAL 313 .83
1 hereby affirm that I am exempt from the Contractor's Llcense Law S$grn wfth One Branch Circuit o.
for the following reason (BoOon 7031.6, Business and Profeselone Addttlonsl Sign Branch Clrcuita CECK 013■$3
Code): .00
r-11, as owner of the property,will do the work and the structure Mlec.Conduit S Conductor
Is not Intended or offered for sale (Section 7044, Business Other(See Complete Fed Schedule) '
and Profeealons Code).
O00D— QO1 /�y�2r9y I+9y 2
CONSTRUCTION LENDING AGENCY
v7 1 rf 11V:L4
I hereby affirm that there Is a construction lending agency for the Q +
performanoe of the work for which this permit Is Issued (Sec. 3087, PERMrT FEE (Sub-Totai) a s'/
Ctv.C.) y
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE a�
Lenders Address `
I certtfy that I have read this applkc�ant under penalty of purjury state. TOTAL FEE
that the above Information fa correct. I agree to comply with all County
ordtrhances and State laws reguktdng Electrical wiring,and hereby authortze
repraeenttives of this County to enter upon the above-mentioned property
for Inspection purpose& ` BEE REVERSE FOR EXPLANATORY LANGUAGE
e�rv. DATE