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HomeMy Public PortalAbout5805 ENCINITA AVE_Electrical__ WORKER'Shave a certificate DECLARATION 7GA060 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby a0irm that I have a certificate of consent to self Insure, of 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 JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY Y ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.FL 145 z6 S $ NEAREST department. Multifamily Sq.Ft. CROSS Si. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE' Outlets:Rec._Light Sw. IRA First 20 MAIL (This section need not be completed If the work involved by the 1 ,t '.- ' ` I '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 Tal.No. is issued, I shall not employ any person In any manner s0 as t0 PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Q Total No. Additional Date 7V�/—�� Applicant � � �' /� � ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No. Exemption, you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP. rovisions of the Labor Code, you must forthwith comply with such PER PPower Apparatus 8 Large Appliances APP provisions or this permit shall be deemed revoked. LICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 7" -dY I hereby affirm that I am licensed under provisions of'Chapter 9 Over 3 to 10 Ind. �/ (commencing with Section 7000) of Division 3 of the Business and CITYS rz1vi 2�-� Tel.No.B-�W.J?X_ Professions Code,and my license is in full force and effect. Over 10 to 50 Ind. LICENSE OR Over SO to 100 Ind. REG.NUMBER S70,55!-7 Class. A } a /r . R C ED BY 0 License Number 5-70 4 7 7 Lia Class Cho Over 106 DISTRICT NOP � Q (� Services,Swbd.,MCC&Panelboards Contractor G/1FN-CHtlrw 4re Data /0 9�/ 0-399 Amp.Under 600 V FATE 0 ❑ I am exempt under Sec. 400 1000 Amp, Under 600 V If VALIDATION U Over 1000 Amp.or Over 600 VW BY AL d 8.8P.C.for this reason BRANCH CIRCUIT FEES (n Date: 15A,or 20A. 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp. Power Pale&Appurtenances d HOME OWNER-BUILDER DECLARATION - �i'•'T I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 33 - 152li Code): ❑ �' -I � . I, as owner of the property,will do the work and the structure Misc.Conduits 8 Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) © T�;T?' 175�'�+ = and Professions Code), 1=12=i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the (:F10Lr •l.ljl performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE j (Sub-Total) 2 Civ.C.) PLAN CHECKING FEE ),t A 10(191r.�r it n* Lender's Name -I'1_;_ ,,. PERMIT ISSUING FEE �i (�('+� .. Et ?• ; . Lender's Address ` ! L 1 certify that I have read this application and under penalty of purjury 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 of this County to enter upon the above-mentioned property for Inspe Ion oses SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNAT�V OFl`ERMI� DATE