HomeMy Public PortalAbout5801 ENCINITA AVE_Electrical__ WORKER'ShaveCOMPENSATION DECLARATION 76A663 0PW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm that I have a certificate o1 consent to self insure, 76A663 M
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 AOORES9 Q
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
LOCALITY
_ $
F-1
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft.; r $ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSMAP OR PAGE PARCEL
'CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rea_Light Sw. OWN NAME
COMPENSATION INSURANCE
First 2D
(This section need not be completed If the Work involved by the . Additional MAIL MAIL
Total No5
permit is for one hundred dollars($100)or less.) _
I certify that in the performance of the work for which this permit CITY Tel.No,
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 /V'f-� - Applicant Al,--U IWC RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: it, after making this Certificate of CITY T.I.No.
Exemption, you should become,subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
IT
provisions of the Labor Code, you must forthwith comply with such Power Apparatus 8 Large Appliances APPLICANT ,F
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10Ind.
J�
(commencing with Section 7000) of Division 3 of the Business and CITY /tq,�pJ, Tel.No.
Over 10 to 50 Ind. LICENSE OR
Professions Code, and my license is in full force and effect. / }
Over 50 to 100 Inc, REG.NUMBER /Q(�'7 Class. J 0
Over 100 DISTRICT NO, PROCESSED BY
License Number Lic.Class
7 Services,Swbd.,MCC&Panelboards d4 Q
Contractor �N/E/V—C/(�i(F�/✓!'�•c_Date lJ /�—/y 0-399 Amp.Under 600 V DATE h-
VALIDATION
❑ am exempt under Sec. 400-1000 Amp.Under 600 V W
Over 1000 Amp.or Over 600 V FINAL UU
B.&P.C.for this reasonBY 00
BRANCH CIRCUIT FEES
Date: 15A,or 20A, 120V,Lighting or Recept. ?
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F-141 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits _
SINGLE FAMILY Temp. Power Pole&Appurtenances J.
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
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
❑ 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors _Tf:r71
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) T'
_ ® w 'L -a s=
and Professions Code). -
CONSTRUCTION LENDING AGENCY :
1 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 !f Ef" - v•�.�
Lender's as '
I certify that at Ihave read this application and under penalty of perjury 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 ei ihi unty to [ e above-mentioned property
for inspe as 4 SEE REVERSE FOR EXPLANATORY LANGUAGE
SOF PE MITTEE DATE