HomeMy Public PortalAbout4927 CLOVERLY AVE_Electrical__ VV,,that I'S COMPENSATION DECLARATION 76A669 DPW 9/89 'APPLICATION FOR ELECTRICAL PERMIT
76A663
I heI'fby aifirm�that I have a'certificato 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.) \�f'
POi'ICy NO. � La�^' Company r-'-J FOR APPLICANT TO FILL IN AD
❑
ADDRESS �
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
$ _ $ LOCALITY
Certified co is filed with the cou in inspection 1 &2-Family,Sq.Ft.
PY g P _ NEAREST -� n K
de rtmen,n Multi-family Sq.Ft. CROSS ST. (�-l7
Dat ` Applican Residential Swimming Pools ASSESSOR �J
.MAP BOOK , PAGE !+^� 1PARCEL�[�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. FlRM NAME
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAILry
D
Total No. Additional ADRESS G"Jb
permit is for one hundred dollars($100)or less.) �, �e�
I certify that in the performance of the work for which this permit CITY ` Tel.No. / /1(l�
is issued, I shall not employ any person in any manner so as to PLAN CHECK -�T`�6
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
APPLICANT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >_
LICENSED CONTRACTORS DECLARATION ADDRESS a-
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH O
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. V
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR p (c
�,a�� Power Apparatus&Large Appliances REG.NUMBER
i Class. O O
License Number Gi `�—` Lic.Class�_(yn� Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY U
Up to 3 Incl �.�$ ill
FINAL
ContractoF�.e� ��`� Date Over 3 to 10 Incl.clDATE Z
Over 10 to 50 In . /r Z
❑ I am exempt under Sec. Over 50 to 100 Incl. Z —'7 VALIDATION "-
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201 -1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V _
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit n
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
Code):
I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) „.-;-' _ c,-,
and Professions Code). , ,;•
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)
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address �* `
I certify that I have read this application and state that the above TOTAL FEE (p
form
d ation is correct. I agree to comply with all County ordinances
State regulating Electrical wiring, and hereby authorize
e i ves of this County to enter upon the above-mentioned
r i pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
0-7
OF APPLICANT OR AGENT ATE