HomeMy Public PortalAbout5803 1/2 ENCINITA AVE_Electrical__ '.WORKER'S COMPENSATION DECLARATION DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT - IJ
6A663
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 No. Company FOR APPLICANT TO FILL IN JCB ` / Gv�r,
❑ ADDRESS S T/oie
Certified copy is hereby furnished. New Residential Bldgs.8 Pools NO. EACH FEE
❑ _ $ • $
-LOC Ty
/E err
Certified co is filed with the count building inspection. 1&2-Family.Sq.Ft. l fW,�
department. y g p Multi-family S .Ft. NEAREST
p Y 9 _ CROSS ST.
Date Applicant Residential Swimming Pools -MAP SSOR
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light_Sw._ OWNER R OR
COMPENSATION INSURANCE 2J
First 20 MAIL
(This section need not be completed If the work involved by the Total No. Additional .�'!- r '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, I shall not employ any person In any manner se as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT -
/ Total No. Additional ADDRESS
Date w^/Y—P/Z' Applicant N�U ��C'
NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3HP. 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 . . AFPLCANT � /-4/C
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances n
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 9' r �-` �///6p•
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl. CITY S FL/L4m. t T.I.No.
Professions Code,and my license is In full force and effect. Over 10 to 50 Incl. LICENSE B 7 }
Class. /��/
Over 50 to 100 Incl. REG.NUMBER 0�7 t_ /V a
License Number / 7^f /1/v Over 100 DISTRICT NO. �� y PR SED 0Y O
'S/ K/'/ / Lic.Class C
- /r Q Services,Swbd.,MCC&Panelboards
Contractor G7110i' -C1101-11,44y•" Date /(J 9 0-399 Amp,Under 600 V FINFATE
❑ 400-1000 Amp.Under 600 V W
I am exempt under Sec.
Over 1000 Amp.or Over 600 V _ VALIDATION
NAL Il
B.&P.C.for this reason BRANCH CIRCUIT FEES BY Of)
Date:
15A,or 20A, 120V,Lighting or Recepl. z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,2DBV To 277V Lighting Br.Circuits ,
SINGLE FAMILY Temp.Power Pole&Appurtenances '
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit r�1
for the fallowing reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ---- (�
14tI v iT
Code): -'
F-1 1, Conduits&Conductors
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) i 2
and Professions Code). S-
CONSTRUCTION LENDING AGENCY SL r• r 1.G r�+.t
1 hereby affirm that there is a construction lending agency for theC Ll1- LI
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) •C,
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE AN ✓•'ry
Lender's Address /
I certify that I have read this application and under penalty of perjury slate 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 t anter upon the above-mentioned property
for inspectipn a os ql SEE REVERSE FOR EXPLANATORY LANGUAGE
S IATURE OF PERMITTEE DATE J