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Home My Public Portal About4905 ENCINITA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT 76A663 I hereby affirm lila[ I have a certificate of c nsent to self insure, 76A663 or a certificate of Worker's Compensation I surance, or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 800 Lab C) b Policy No Company �D \ FOR APPLICANT TO FILL IN 'OBADDRESS r C �e "❑ Certified co is her furnis d NO EACH FEE PY New Residential Bldgs &Pools _ LOCALITY • Certified copy is filed wit a cou d g in cti 1&2-Family,Sq Ft _ $ $ NEAREST department Multifamily Sq Ft CROSS ST Date .57— �� plica Residential Swimming Pools ASSESSOR Q� MAP BOOK U PAGE �I PARCEL y CERTIFICA F EXEMP N,F ORKERS' I OWNER OR / Outlets RBC Light Sw- FIPM NAME G7 COMPENSATION INSURANCE MAIL - First 20 , At Ao (This section need not be completed If the work Involved by the ADDRESS permit is for one hundred dollars($100)or less) Total No Additional f ld/ I certify that in the performance of the work f!—ant chis perm A � Tei N 4-2,�Od is issued I shall not employ any person in� r so as to PLAN CHECK become subject to the Workers' Compensan Lighting Fixtures First 20 APPLICANT Total No Additional ADDRESS Date J - Applic RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE,TO APPLICANT , a r making this ificate of CITY Tel No Exemption,you should bec a subject to the Wo ers Compensation OTHER APPLIANCES NOT OVER 3 HP provisions of the Labor ode, you'must forthwith comply with such PERMIT P Y P Y _- APPLICANT provisions or this permit shall be deemed revoked > -Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS E C4GJQ,l — rJ L I hereby'affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl ,// (commencing with Section 7000) of Division 3 of the Business and CITY ��VG Tel No ,�, Professions Code, and my license is in full force and effect Over 10 to 50 Incl LICENSE ORClass Over 50 to 100 Incl REG NUMBER </Z j3 IZ C,��3 V Over 100 DISTRICT NO P O SED BY O License Number Lic Class V /-� d ,// 2 Services,Swbd,MCC&Panelboards0 cc FINAL 0 Contracto��A7C T(JICV.Ld �Date �/ ��J 0-399 Amp Under 600 V l DATE ❑ - � 400-1000 Amp Under 600 V Z / I am exempt under Sec VALIDATION W Over 1000 Amp or Over 600 V FINAL - -B&P C for this reason BRANCH CIRCUIT FEES BY a Date 15A,or 20A;120V,Lighting or Recept Z - 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits " ❑ 41 Or More Branch Circuits m Exeption for Reg Maint Elect 15A, ,20 Tc 277V Lighting Br Circuits SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER BUILDER DECLARATION - P��ljog I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Circuit' - for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits v17 5o7�I Code) ❑ I, as owner of the property,will do the work and the structure Misc Conduits&Conductors 1 !TEM- is i E r'7�fd� _ �"- d-p is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 50 m 9* 0 and Professions Code) :'_ CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending,agency for the CHANGE °011 performance of the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub-Total), r Civ C) �d PLAN,CHECKING FEE I� ,;I�-UI I 5"14/9 ,Lender's Name C - PERMIT ISSUING FEE p� M 8:5-1, Lender's Address - A I certify that I have read this application and under penalty of purjury state TOTAL FEE that the'above informatI correct I agree to comply with all County ordinances and St u ating Electrical wiring,and hereby authorize representativ thi ounty to enter upo the above mentioned property for ins p oses SEE REVERSE FOR EXPLANATORY LANGUAGE ' /7 J' ATURE OF PE DATE