HomeMy Public PortalAbout5803 ENCINITA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 200019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT IJ
76A663
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(S6o.5800 Lab. C.)
Pp11Cy N0. Company FOR APPLICANT TO FILL IN AOB
DDRESS SD✓� �n c.�n�• c� �}r.
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ 1 8 2-Family.S9 FL 15-6_ - $ , $,//70
Certified copy is filed with the county building inspection NEAREST 1 /
department. Multifamily Sq.Ft. CROSS 61. K m,pia—��
Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR
COMPENSATION INSURANCE Outlets:Rec._Light_Sw. FIRM NAME
First 20 MAIL
(This section need not be completed If the work involved by the Total No. Additional 1 ADDRESS
permit is for one hundred dollars(5100)or less.) -
I certify that in the performance of the work for which this permit CITY Tel.No,
is issued,.) 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
Dale Date Applicant_,��u �� RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, alter 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 complywith such PERMIT N U. /N_
provisions or this permit shall be deemed revoked. /
Power Apparatus&Large Appliances APPLICANTF. (.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW.KVA,or KVAR ADDRESS r W M�O�
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 CITU ��,y(�fy(/ TOL No.d.
Professions Code,and my license IS In full force and effect.
Over 101e$0 Ind. LICENSE OR �-/
Over 50 to 100 Inc. REG.NUMBER .> / Class. C'�/J d
rV Over 100 DISTRICT NO. J PR E SED B� O
License Number ✓ �7 7 Lia Class -/ Q
/ Services,Swbd.,MCC&Panelboards
Contractor Ci/�6t!-Cpa..W Dale !el 19-L 1O-399 Amp. Under 600 V GAFINTE 0
❑ 400-1000 Amp.Under 600 V VALIDATION V
am exempt under Sec. W
Over 1000 Amp,of Over 600 V FINAL
B.BP.C.for this reasoneY
EL
BRANCH CIRCUIT FEES
Date: 15A,or 20A. 120V.Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑
41, More Branch Circuits
Exemption for Reg. Maint.Elect. 15A,20A,200V To 2T7V Lighting Br.Circuits `
SINGLE FAMILY Temp.Power Pole&Appurtenances A __
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit rt1
I hereby affirm that I am exempt from the Contractor's License Law y- --�,�-,- c
for the following reason (Section 7031.5. Business and Professions Additional Sign Branch Circuits :F-' X65•2:
Code): - f F1 1,1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D T'!, 1.65 - 2 4'
and Professions Code). �� I,=-,Z
i-7
CONSTRUCTION LENDING AGENCY
`.pA..- <<ILI
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 ' _ h` "��-_I}i;I VIM/92
Lender's NamePERMIT ISSUING FEE,
i fad +- .I
Lender's Address S /
I certify that I have read this application and under penalty of perjury state TOTAL FEE (v O(
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 properly
�AT
ur SEE REVERSE FOR EXPLANATORY LANGUAGE
MI DATE