HomeMy Public PortalAbout5229 FARAGO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm ghat I have a certificate of consent to self insure, 76A663
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(Sec1 GIT .) � 1
Policy No. 1 mpany y\C FOR APPLICANT TO FILL IN JOB
IL'L�ll. ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Popl _ NO. EACH FEE
$ $ LOCALITY
Ong
❑ Certified copy is filed with the county b Idi nsp tion 1 &2-Family,Sq.Ft.
NEAREST `�
department. Multi-family Sq. Ft. CROSS ST.
Residential Swimming Pools ASSESSOR
Date Applicant
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM W ERS' Outlets:Rec._Light Sw. OWNER
NAME
COMPENSATION INSURANCE
First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS c �l' at..�\�
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY VVIrio—, Q
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.
provisions of the Labor Code, you must forthwith comply with such PER
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
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 CITY<;Zr� �� !%
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSE
Over 50 t0 100 Incl. REG.NUMB Class. C
BER
a
Over 100
License Number `� Lio Class `c DISTRICT NO. p PRO1 0
CEED BY O
"FjServices,Swbd.,MCC&Panelboards
ContractDate er` 0-399 Amp. Under 600 V FINAL
DATE 0
ElI am exempt under Sec. 400-1000 Amp.Under 600 V Y Z Z 3 VALIDATION U
Over 1000 Amp.or Over 600 V FINAL LLI
a
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
El
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
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
Code):
❑ Misc.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) '
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
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 thi ounty o enter upon the above-mentioned property
for inspectio rp SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUR O DATE