HomeMy Public PortalAbout6243 GOLDEN WEST AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm'4hat I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY Or LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOBADDiH
2 Q
Certified copy is hereby furnished. New Residential,Sq.Ft. $Bldgs.&Pools NO. EACH FEE LOCALITY `
❑ ��� — $� a
Certified copy is filed with the county building inspection 1 &2-Family, _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASS BOOR Q p r
^il 10PAGE OR
PARCEL a��
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FFIIRM NAME
COMPENSATION INSURANCE First 20
(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.) CITY Tel.
/-
1 certify that in the performance of the work for which this permit /��7r "�,
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 Ct RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOT(CE TO APPLIC T: If, atter making t is 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
p p y Power Apparatus&Large Appliances APPLICAN7i '
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 CIT - ��A t e Tel.N
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR �}
Over 50 t0 100 Incl. REG.NUMBER Class. O
/� Over 100 DISTRICT NO. PROCESSED BY 0
License Num r Lic.Class� p
Services,Swbd.,MCC&PanelboardscF NALa
Contract o•10alw GF n mf L X2-0 0-399 Amp.Under 600 V DATE O
❑ 1 am exempt under Sec. 400-1000 Amp.Under 600 V J-� VALIDATION W
Over 1000 Amp.or Over 600 V FINAL G_
B.&P.C.for this reason BRANCH CIRCUIT FEES BY ( Z
Date: 15A,or 20A, 120V,Lighting or Recept. I y
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Ryg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY
Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION i7�•t•I a.aV•
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law SigL;`7 49-,.15,
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 1## ITEMS
EMS
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors C
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOT! AL. 197 - 19
and Professions Code). r q�}7 ;k!
CONSTRUCTION LENDING AGENCY CHANGE .00
I hereby affirm that there is a construction lending agency for the CHANGE
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.) _
PLAN CHECKING FEE 0530 I--SJR I[11 111201/93
Lender's Name I cc
PERMIT ISSUING FEE �7` (. - AM11'.55
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE ��P71 g
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 this County to enter upon the above-mentioned property
for inspection rp es .-20 SEE REVERSE FOR EXPLANATORY LANGUAGE
\NATURE OF PERMITTEE DATE