HomeMy Public PortalAbout6037 CLOVERLY AVE_Electrical__ WORKER'S I S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that have a certificate of consent to self insure, 76A663
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.) r
Policy No. 1316 1Z _%Company S ti RTG `V.a! ) FOR APPLICANT TO FILL IN JOB
❑ ADDRESS 6 `o r Overt Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY� �t
❑ 1&2-Family,Sq.Ft. — $ $
Certified copy is filed with the my b Ild g pection NEAREST
depart m nt. Multi-family Sq.Ft. CROSS ST. c 1 v y
Date Applicant Residential Swimming Pools MAPBOOK � (O
p ` PAG PARCEL
CERTIFICATE OF EXEMPT FROM WORKERS' Outlets:Rec._-�Light Sw. OWNER OR 4 _{, ip
9 D FIRM NAME Jc�n . 'Debi v 5t��py
COMPENSATION I SURANCE ,gQ
First 20 MAIL
(This section need not be completed if the work involved by the Total No. 2-9 Additional ADDRESS to037 C O J z,
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY
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
Date Applicantn
NOTICE TO APPLICANT: If, after making this Certificate of REI A APPLIA CES OVER 3 HP. CITY "3r• Tel.No. l� �20
_6�{ ti{O
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith complywith such PERMIT
Power Apparatus&Large Appliances APPLICANT e
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 3�'�1 1,
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10.lncl. (�
(commencing with Section 7000) of Division 3 of the Business and CITYAe
v Tel.No. "L� �L
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. >_
LICENSE .. Class. g a
Over 50 t0 100 Incl. REG.NUMBER
j ER f SIS
Rt7 o
/ 8a Over 100 DISTRICT NO. P C SSED BY U
License N b �O Lic.Class �h O' CLytC� O
Services,S%..,,MC &Panelbo ds !/dcr
FINAL
Contractor Date ^Zf—9` Under 600 V DATE H
❑ 400-1000 Amp.Under 600 V !� 7-q w
I am empt under Sec. VALIDATION
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY �) Z
Date: 15A,or 20A. 120V,Lighting or Recept. (/ —
1 To 10 Branch Circuits
Signature '� 11 To 40 Branch Circuits
El Exemption
Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 4rr Y
SINGLE FAMILY Temp. Power Pole&Appurtenances ACC t ng
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit t1 i 7
I hereby affirm that I am exempt from the Contractor's License Law g )303 153.r0
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ITEMS
1 i` M t
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 153 - 70
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee hedule) , CHECK.�� 153.70and Professions Code). Iii
CONSTRUCTION LENDING AGENCY CHANGE e00
I hereby affirm that there is a construction lending agency for the n
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Oy
Civ. C.) 0000-0001 6/25/96
PLAN CHECKING FEE 7107 1 PM 1:44
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE Q
that the above information is correct. I agree to comply with all County
Erspecti
es d State laws regulating Electrical wiring,and hereby authorize
tat' e o is County to enter upon the above-mentioned property
n p ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
C-Zs-9G
tfURE OF PERMITTEE DATE