HomeMy Public PortalAbout5957 ENCINITA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 260019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby-affirm that i have a certificatecate of consent t0 self insure, 60663
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 JOB
75ADDRESS q 5 1
❑ - Certified copy is hereby furnished. New Residential Bldgs.&PI NO EACH FEE
1 &2-Family,Sq.Ft. * — S LOCALITY
❑ Certified copy is filed with the county building inspection _ NEAREST
department. Multi-family Sq.FL CROSS ST.
Date Applicant Residential Swimming Pools ;Ag1`BOOK
PAGE 4 PAflCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Roe.—Light_Sw._ OWN Nn OR
LA COMPFIRMENSATION INSURANCE - Its fl
(This section need not be completed if the work Involved by the First MAIL
Total No. Additioio nal ADDRESS 4 (�
permit is for' ne hundred dollars($100)or less.) -
I certify that in the performance of the work for which this permit CITYSh N. Tel.No.'47.`042
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 tC(T—Applicant ki CY �CG`•/r�' RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, afterr making thiss 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 comply PERMIT
p p y with such APPLICANT W v e
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 4S rovaeAu I C
I hereby.affirm that I am licensed under provisions of Chapter 9 Over 3 to 101nc1.
(commencing with Section 7000) of Division 3 of the Business and CITY �U el Tel.No. HOZ
and m license is in full force and effect. Over 10 to 50 Ind. LICENSE OR }
Professions Code, y 5.7-�s'3 CId99.
Over 50 f0 100 Incl. REG.NUMBER
Over 100 DISTRICT NO. PR E111
Q
License Number 3y Lic.Class G-(d i � / (�
Services,Swbd.,MCC&Foreheads -J ` 2,G�-yy4/ Q
Ll l/L �tA/( �� 2 Date 1, �q 0-399 Amp,Under 600 V FINAL Q
Contractor DATE
❑
4001000 Amp,Under 600 V – Z f.%'C,S VALIDATION V
am exempt under Sec.
Over 1000 Amp.or Over 600 V W
0.
B.&P.C.for this reason BY AL W
BRANCH CIRCUIT FEES (n
15A,or 20A.120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits i
Exemption for Reg.Mail Elect. 15A,20A,2D8V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances s
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that am exempt from the Contractor's License Law g T; Pic, rt0
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits �'�f:=' lr `���
Code): 1 T TENS
❑ I,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)_ - TO L 3 7 35_- 60
and Professions Code). CHECK 4/15.60
CONSTRUCTION LENDING AGENCY CHAN(;Y ,00
I 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 UUCIU VLILI l j: U,r9
Lender's NameC y R:L.7
PERMIT ISSUING FEE G �'�it il� 1 Art -
Lender's Address
certify that I have read this application and under penalty of purjury state TOTAL FEE 6.
that the above informaI'sct. agree to comply with all County
ordinances and State laElectrical wiring,antl hereby authorize
reprosentalives of er upon the abovementi0ned property/or in i n put osesSEE REVERSE FOR EXPLANATORY LANGUAGE
I / �J—YF-1,L
SIGNAT E OFAERMIMFEE DATE