HomeMy Public PortalAbout9008 GARIBALDI AVE_Electrical__ woflKER'S COMPEN8AT10N DECLARATION 20-0019 DPW(12-91)
701WAPPLICATION FOR ELECTRICAL PERMIT
I hereby affirm thea I have a certlflcete of oonsent to &elf Insure,
or a certfflcate of Worker's Compensatlon Ineurence, or a certlfled COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
oopy thereof,(Sec.3800 Lab.C.)
POLLCY'No. Company POP APPUCANf TO F91 IN
Certlbed oopy h M1eroby fumished. New Residential Bldge..&Poole NO. EACH FEE LOCALITY
❑ C&rtffW copy Is flied with the county building tnspeotlon 1 &2-Family,Sq.PL�L— — $�L $
NEAAM
depertrnent MuftWsmlly 8q.FL CROSS ST.
Deis App0oant Pssk$sntlal Swlmming Pooh AggEggpR
MAP < � PAGE!/ P .
CERTIFICATE OF EXEMPTION FROM WORKERS' Outtets;Reo._Light 8w. OWNER off
COMPEIp
NSATN INSURANCE RF11t NAME
Flret
(Thls'sectlon need not be completed If the work Involved by the X89
permit la for one hundred dollars($1 DO)or less.) Total No. Additional
I certify that In the performance of the work for which this permit I-IN T.L
Is Issued, I shall of em loy any person In any manner so as to Pty1 CHECK
become Jeal t e W r:�Y-eatl we. Lighting Fbrhu&s Fln1 20 APPLIGANr
fl— Total No. Additional
ADDRESS
DeL RESMEMIAL APPLIANCES NOT OVER 3 HP.
NOT TO„A PLIC NT: If, after making this Certificate of C1TY Tel,Na '
Exemption,you hould beoDma subject to the WQrkore' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisionsof the Labor Code, you must forthwtth oomply with such PUSS
provlslons or this permit shall be deemed revoked. Apperattu&��
voked. APPUCAFfr
LlbaNS D CONTRACTORS DECLARATION Stze&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter B Over 3 to 10 Ind.
(oommenoing with Seotlon 7000) of Dlvislon 3 of the Business and CITY TOL
ProfeasJone Code, and my license Is In ull force and effW. Over 10 to 60 hid.
L Over 60 to 100 Ind. RFA Nl1AtBEA R
Lloorm Number Lb.Claw. Over 100 DtBTRiCT NO. J� BY
SeMtb
oes,Swbd.,MOO&Paneoerds -v d
Contredor I 0-399 Amp.Under 600 V DATE / Q
B�#4
4400-1000 Amp.Under 600 V .g V
❑ I Am exempt under Seo. Over 1000 Amp.or Over 600 VVALIDATION IJJ
RNA!- IL
B.&P.C.for tt le reason BRANCH CIRCUIT FEES BY U)
Dole. 16A,or 20A, 120V,Lighting or Reaept
Z
1 To 10 Branch Clroufs
11 To 40 Brandi Ckatte
41 Or Moro Branah Clroutrn
❑ ExempUon-for flee.Malnt BeoL 16A,20A,206V To 2 7V Br.Cts fb
SINGLE FAMILY Temp.Power Pole&Appurtenances yr i
HOME OWNER-BUII�ER DECLARATION) One Bnnoh Circuit ACCT•w
I hereby affirm that I am exempt from the Contractor's License Lew g� -��--.��,�--�� ?G4.61
for the following reason (Section 7031.6, Buelneea and Professlons Additional S$gn Nwioh Clrcufta 33'3
Code):
�l ,x,11 ITEMS ,[
❑ 1, as owner of the property,will do the work end the structure Misc.Conduits&Cpnductora TOTAL +C��T
Is not Intended or offered for sale (Seotlon 7044, Business Other(See Complete Fee Sohedub)
- 69
and Professions C(>de). , (VECY, 204.69
CONSTRUCTION LENDING AGENCY .I0I
1 hereby affirm that there Is a constructlon lending agency for the
performance of the work for which this permit Is Issued (8ec. 3097, PERMIT FEE (Sub-Total)
CIV.C.) PLAN CHECKING FEE LRJ�Utr+�'�'-1 5/26/?4
Lendeee Nam•
PEAMff ISSUING FEE 1 AM :K.
Lender's Address
I certify that I have reed th s app6o0on and under penalty of pu”elite TOTAL FEE
that the above IntorrnatIm is oorrect. I agree to comply whh all County
ordinances and State lave mgulatt V Eleobloel wiring,and hereby orize
Of this ty to enter the ed
purposes- � /y SEE REVERSE FOR EXPLANATORY LANGUAGE
903MTUFLE OF P6e•TfEE MTE