HomeMy Public PortalAbout6249 GOLDEN WEST AVE_Electrical__ WORKER'S COMPENSATKxJ DECLARATION 0019°P"(12-91)
7M,EE3 APPLICATION FOR ELECTRICAL PERMIT
I hereby itfflrm that have a oertlflcate of oonsent to self Insure,
or'a oardflcatatof Worker's Compeneallon Insurance, or a certlfled COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy'thereof(Seo.3800 La-lb.C.)
Policy No. Company POR APPUCANr TO I9LL IN A�D4REBB
❑ Cwttw copt Is hereby fumished. New Reeldentlel Bldgs.8 Poole/G NO. EACH FEE
❑ — i { LOCALITY
CertfM1ed copy Is filed with the county building Inspection 1 S 2 Farnity,Bq.FtNEAREST
department- Multl4snn By Sq.Ft CFKM ST.
Date Appkarrt Reeidantal Swlmmlrp Pools ASSESSORMAP PAGE amca a/
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. N R
COMPENSATION INSURANCE
ME
(This section need not be completed It the work Involved by the
F1 rat 20 ��
PaRnn Is for onn s hundred dollars(1100)or lap.) Total No. Addftlonal g /
I certify that In the performance of the work for whlch this permit T�
Is Issued, I shall not employ any person In any manner so as to PLAN a-�
become subject to the Workers'Compensation taws. Lig Ening Ftxturea F1 rat 20 APPUCANT
Total No. Additional
L_ ADDRESS
Dal 20 L_
RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOT E TO APP NT: If, after making thls Certificate of CSTY TOL No.
Exemption,you should become subject to the Workers'Compensatlon OTHER APPLIANCES NOT OVER 3 HP.
provlslons of the Libor Code, yQu must forthwith comply with suchMIT
prWalons or this permit ehalt be deemed revoked. Power Apparatus 8 Large A'ppllancee
LICENSED CONTRACTORS DECLARATION Stze S Type HP,KW,KVA,or KVAR ADDRESS r
1 hereby affirm that I am licensed under provlslonp of Chapter 9 O1ef 3 to 10 Ind.
(commenclhg with Section 7000) of DIvlslon 3 of the Business and NO' t7
Professions Code,and my lloense Ia In full foroe and affect. T Over 10 to 60 Ind. UClNBE
OR
Over 60 to 100 Ind. FEO.N01,1BER a"L d
�//� fiver 100 D03TRJCT NO. BY
License Number Llo.cies.�cLLL
Sarvices,Swbd.,MCC a Panelboarda �� .t.r�G✓
Contractor Date 0-399 Amp.Under 6W VDATE
FINALo
❑ Ism exempt under Seo. 400.1000 Amp.Under eA0 V .i(U—� VALIDATION V
over 1000 Amp.or Over 000 V FfNAL BY d
B.BP.C.for this reason BRANCH CSRCUrr FEES _
Data: .r 160.or 20A,12OV,Lighting or Recept Z
1 To 10 Brash Clroults
re 11 To 40 Branch ClrtuPor
❑ 41 Or Alone Branch Ctrcub
Exemption for Reg .
Elect. 160.20A,200V To 277V Br.CYcults
HOME OWNER-BUILDERSINiGLE Temp.Power P d Appurtenances HOME
I hereby affirm that I am exempt from the Contractor's License Law Sign wHh Ona Branch
rwh Chcuh i
o O
for the following reason (Section 7031.6, Business and Profeealons AddlHonal Sign Branch CSrcults 3W7 197.19
Code). 1 ITEMS
❑ 1, as owner of the property,will do the work and the structure Mlec.Conduits S Conductors T 1 i
Is not Intended or offered for sale (Section 7044, Business Ottler(See CgTOTAL-Fee Schedule) t O 113- 19-7 - 19
and Profearions Code).
CHECK 197.19
CONSTRUCTION LENDING AGENCY 00
I hereby affirm that there Is a construction lending agency for the `^•""- W
performance of the work for whlch this permit Is Issued (Seo. 3097, PERMIT FEE (Sub-Total)
Chi.C.)
PLAN CHECKING FEE 900D-"1 V20/93
L.endWs Name PERMIT ISSUING FEE 7725 1 AM 11:56
Lenders Address
I certify that I have read thls appkation and under penalty of purjury state TOTAL FEE
7 9
that the above InfomratIon Is correct. I agree to comply with all County
ordinarwee and State Taws rag u10ng Eleotrlcal wiring,and hereby authortre
repreeentettvee of thie County to enter upon the above-mentioned property
for I SEE REVERSE FOR EXPLANATORY LANGUAGE
BrONA GATE