HomeMy Public PortalAbout5225 FARAGO AVE_Electrical__ iWORKER'S COMPENSATION DECLARATION 9 DPW(1291)
76A663 APPLICATION FOR ELECTRICAL PERMIT LJ
76A66
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. 380Q L ) / 4.�1A t—
Policy No. 6 t \3 mpany a l� FOR APPLICANT TO FILL IN ADDRESS
>a-�-� �Int Q0A G.,c7
Certified copy is hereby furnished. New Residential Bldgs.&P�o t) NO. EACH FEE LOCALITY
❑ Certified co s filed with the count ild' s tion 1 &2-Family,Sq.Ft. _ $ $
PY Y P NEAREST F
^^department. Multi-family Sq. Ft. CROSS ST. l rc
Date pplicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WO4RS' Outlets:Rec._Light Sw. FFIIRM NAMEA 6
OR
COMPENSATION INSURANCE
First 20 J
(This section need not be completed if the work involved by the Total No. Additional ADDRESS c `� •�� L
permit is for one hundred dollars($100)or less.) 1 JQ
I certify that in the performance of the work for which this permit CITY` TY r
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 Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
PERMIT1 .
p.,,
provisions of the Labor Code, you must forthwith comply with such Power Apparatus&Large Appliances APPLICANT o CC h
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
1 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 CITY Ktkq_ 4:,&R. lid
Professions Code,and my license is in full force and effect. Over 10 t0 50 Incl. LICENSE OR 1S`�`�� Class. d
License Number G l
Over 50 to 100 Incl. REG.NUMBER
1
ilt!SAV-� C, Lic.Class C ii, Over 100 DISTRICT NO. PROLE D BY Q
�) G
` tet} C Services,Swbd., MCC&Panelboards
FINAL Cc
Contractor aE ` 1 Date ,y I 0-399 Amp. Under 600 V DATE 0
❑ 400-1000 Amp. Under 600 V
I am exempt under Sec. VALIDATION U
Over 1000 Amp.or Over 600 VWFINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg. Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
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
Code):
❑ 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) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY
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
Lender's Name _
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE a O
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
represeX( VO_r
to enter upon the above-mentioned property
for inspSEE REVERSE FOR EXPLANATORY LANGUAGE
t o—os
SIGNATURE Ill DATE