HomeMy Public PortalAbout9560 DAINES DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
h-herbby affirm that I 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.)
Policy NO. Company FOR APPLICANT TO FILL IN JOB
ADDRESS ,� V!!,,
nes Dr
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ 1 &2-Family,Sq.Ft. — $ $
Certified copy is filed with the county building inspection NEAREST Jr
department. Multi-family Sq. Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASS BOOK
PAGE PARCEL
OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light—/—Sw. FFIIRM NAME yj 0A
COMPENSATION INSURANCE First 20 7�
(This section need not be completed if the work involved by the ADD
Additional RESS q(-to (�if Dr'
permit is for one hundred dollars($100)or less.) Total No.
I certify that in the performance of the work for which this permit CITY e CJ' t Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK o
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
APPLICANT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 o ncl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSEClass. a-
Over 50 t0 100 Incl. REG.NUMBB ER fZ
License Number Lic.Class
Over 100 DISTRICT NO. PRZ$ SED BY Q
Services,Swbd.,MCC&Panelboards 9
FINAL
Contractor Date 0-399 Amp.Under 600 V DATE ,(❑ 0 400-1000 Amp.Under 600 V /r1
I am exempt under Sec. T VALIDATION W
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES By a
C/1
Date: 15A,or 20A,120V,Li htin�o/ryR/ec� t. / Z_
1 To YO 8�2n9clC rrcuits
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits
❑ Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits q��+rT
SINGLE FAMILY Temp. Power Pole&Appurtenances p^-5++���r4nnt��ov L7 �t
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit .�{h7 pr°G0
1 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): 1. ITEM
❑ 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors .TOTAL 467-80
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) CHECK 67.80and Professions Code). HC
CONSTRUCTION LENDING AGENCY CH"E e00
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.) �0[ URI
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEF_ Q
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
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
for inspection M��-
_&_ SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PtR9MEE DATE ,