HomeMy Public PortalAbout9028 EMPEROR AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I'hereby affirm that I 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 thereof(Sec.,3800 Lab. C.)
Policy N0. Company FOR APPLICANT TO FILL IN ADDRESS t1
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
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools AS EBOOK ,pp^ �7
PP ,�� (J� PAGE I/ PARCEL Q�O(
CERTIFICATE OF EXEMPTION FROM WORKERS' / OWNER ME Yt
Outlets:RBC. Light Sw. _C9 FIRM NAME
COMPENSATION INSURANCE First 20 ^ _ _
(This section need not be completed if the work involved by the O ADDRESS
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY ` e i I Tel.No.,C T 2f y_,&&,
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 J APPLICANT
Total No._ Additional
`� ADDRESS
Date ya G :3 Applicant Ra�p�7�/ (-n A tRESIDENTIAL 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 )7,0
7
Py ,0 Power Apparatus&Large Appliances APPLICANT �1 . l�lti( U
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. ^_. t��/ L,
(commencing with Section 7000) of Division 3 of the Business and CITY f` t_ Tel.No�I-U` C'��
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR �_
Over 50 t0 100 Incl. REG.NUMBER i2 _ Class.
zf�f '71 Over 100 DISTRICT NO. PR�BYULicense Number OC lD Lic.Class G0
)7 i / Services,Swbd.,MCC ane s !/ Q
Contractor
`,d L P1 �br?���C� Data L9�.�(o �y3 0-399 A . nder 600 V � �"� FDATE
INAL �
❑ 400-1000 Amp.Under 600 VU
I am exempt under Sec. "l 9` VALIDATION W
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z
Date: 15A,or 20.A.120V,Lighting or Recept. 1 —
i 1— 1 To 10 Branch Circuits
Signat 11 To 40 Branch Circuits
01 F-141 Or More Branch Circuits ri
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
q r.r. 3
SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT.•a'
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 3303 9`5
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits r t�
Code): 1 T(Ei i;?
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL `1 95
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
�s t, i 5
and Professions Code). 4.•flECK 112 e
CONSTRUCTION LENDING AGENCY CHANGE .00
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.) 130130—{10011 6/225/93
PLAN CHECKING FEE t�t1 i i.,
Lender's Name 0458 1 Air 37=43
PERMIT ISSUING FEE
Lender's Address 00 O
I certify that I have read this application and under penalty of purjury state TOTAL FEE /0000W?a
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 Cc to ter up the ab mentioned property
JoFirr pection s SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PEITTEE DATE