HomeMy Public PortalAbout6245 GOLDEN WEST AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-9t)
76A663 APPLICATION FOR ELECTRICAL PERMIT
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hereby affirm that 1,have a certificate of consent to self insure,
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(Sec. 3800 Lab.C.)
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Policy No. Company FOR APPLICANT TO FILL IN ADDRESS 6, r
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq. Ft. /9/to _ $� `�' NEAREST
department. Multi-family Sq.Ft. CROSS ST. OF
Date Applicant Residential Swimming Pools ASSESSOR
PP MAP BOOK �,.J�� PAGE 10- PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OR WR NAME `
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the ADDRESS
permit is for one hundred dollars($100)or less.) Total No. Additional a�//
I certify that in the performance of the work for which this permit CITY Tel.
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
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Date ApTotal No. Additional ADDRESS
plicant .
NOT,CE TO APPLI NT: If, after making tl is ertific to of RESIDENTIAL APPLIANCES NOT OVER 3 HPCITY 7e1.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith complywith such PERMIT q
Power Apparatus&Large Appliances APPLICA T f Vie-
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS r'
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Divisiori 3 of the Business and CITe g_ el.N �-
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to 100 Incl. REG.NUM ER �LICENSE OR -_ If q Class.
/�/ Over 100 DISTRICT NO. r' '' PRED BY ✓ O
License Number � Lia ��Class� � y 0 Services,Swbd.,MCC&Panelboards
ContractoW 0-399 Amp. Under 600 V FINAL DATE 0
❑ 400-1000 Amp.Under 600 V �� C•�
I am exempt under Sec. VALIDATION W
Over 1000 Amp.or Over 600 V FINAL
B:&P.C.for this reason BRANCH CIRCUIT FEES BY // ` d
Date: 15A,or 20A,120V,Lighting or Recept. — �`� t (L��— Z_
1 To 10 Branch Circuits
Signature '11 To 40 Branch Circuits
El Exemption
Or More Branch Circuits
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances a
HOMEOWNER-BUILDER DECLARATION t �•�•Taa
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 3311-1
�
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3311 ' z.
Code): I Ct Fe sS
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL O I A 97 9
and Professions Code). K ii0
CHECK t`f97 p
CONSTRUCTION LENDING AGENCY !�t�i r";
I hereby affirm that there is a construction lending agency for the ith1 `UL
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE 0100-000 1/'2
Lender's Name q
PERMIT ISSUING FEE p�� r e 24 1 AN I1:5-r
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 this County to enter upon the above-mentioned property
for ins u SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF/NMIVEE DATE