HomeMy Public PortalAbout4817 FIESTA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 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,tSiereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB ! / t+ j'
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ _ $ $ LOCALITY (17
Certified co Is filed with the count buildinginspection 1 &2-Family,Sq.Ft. n
department. Y p Multi-family Sq.Ft. — CROSS ST. 0!1-e OF-1Z. 4
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' CA 3 OWNER OR,,/
COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM NAME
First 20
'�O MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS (�
permit is for one hundred dollars($100)or less.) �`yy
12
I certify that in the performance of the work for which this permit CITY Tel.N-21 `
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN CHECK
J p g O 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 PERMIT
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 amlicensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to 100 Incl. LICENSE OR
REG.NUMBER Class.
a
License Number Lic.Class
Over 100 DISTRICT NO. P OCESSED BY Q
!'
Services Swbd.,UPC�&_Paanelboards �J' U
cc
Contractor Date ��399,Am-p.Uffder 600 V FINAL DATE 0
El
400-1000 Amp.Under 600 V r I-_
I am exempt under Sec.
Over 1000 Amp.or Over 600 V VALIDATION VFINAL W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY 0-
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits A f.{
Signature - j''
11 To 40 Branch Circuits -,..�-..,_;
F-1
41 Li More Branch Circuits d���p�,((' J - _ F
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits _
SINGLE FAMILY ,I`i -
Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION �, FI#AI
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit d 'r^a `a
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ,,ASH til_;o
Cod,)
:
Zf.'HA�€GE
r I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors o•.li
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) -
and Professions Code).
01000-0—NO J
CONSTRUCTION LENDING AGENCY _
1 herebyaffirm that there is a construction lending agency for the '-� rj y All,
9 9 Y ,,J.°v,,_
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE a�p
Lender's Name
PERMIT ISSUING FEE O
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
representati s Is Co ty to enter upon the above-mentioned property
for inspec' n urpose ✓ r ,� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNAT O PERMITTEE 1 DATE 5