HomeMy Public PortalAbout6247 GOLDEN WEST AVE_Electrical__ v(oRKER's COMPENSATION DECLARATION 2000,0 DPW(12-e1) APPLICATION FOR ELECTRICAL PERMIT
7M DE3
I heFeby dfflrm that F�have a oertlflcato of consent to Belt Insure,
or a'wrdflcate dF Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy tkereof(Sec.3800 Lab.C.)
Polley No. Comparry POR APPUCANT TO 19LL IN
❑ Certified copy Is hereby fumlshed. New Residential Bldgs.h NO. EACH FEE LOCAIJTY
C4wHad copy Is Algid with the county bulldlrtg Inepecm1 S 2-FamIN,Sq.Ft-
on — NEAREST
Multi-funlfy Sq.Ft- cRosa Si.
Ise Appfkant Reelderrtlal 8wlmmlrp I'oofa U P BooK .'S� �r PAGE 4 - PSD'
CERTIFICATE OF EXEMPTION FROM WORKS-WOff;Rec. L1aM Sw.
COMPENSATION INSURANCE "" NAME
20
(This eeotlon need not be oompleted K the work Involved by the Flrst K&L
permit IY for one hundred dollen(1100)or less.) Total tJo. Additional
ADDRESS
I oertify that In the performance of the work for whloh this permit Tj
Is Issued, I shall not employ any person In any manner,so as to PLAN qiECK
become subJeat to the Workers',Compenaatlon Laws. Jghtlnfl F3>chiree First 20 APFUCANT
Total No. Add lidonat
ADDRESS
Dade Applbent RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NO CE TO APPL T: If, after making t s Certificate of CfTY Tet No.
F�emptlon,you should become subject to the Work&&Compenaadon IOT HEA APPLIANCES NOT OVER 3 HP.
provlslons of the Labor Code, you must forthwith oomply with such e Appliances Pm,µr C
prone�Woor Power Apparatus S Large this permlt shall be deemed revoked. �G I y
r
LICENSED CONTRACTORS DECLARATION Size 8 Type HP,KW,KYA,cr KVAR ADDRESS
I hereby affirm that I am Iloerlsed under provisions of Chapter 0 Over 3 to 10 Ind.
(commencing with Section 7000) of Dlvislon 3 of the Business and C (j6/
Profeaalone Code, and my license Is In full force and attest. Over 10 to 60 Ind• UCrNSE OR }
T Over 60 to 100 Ind. REO-Nt11ABE3 r d
g jSZ Over 100 D{8TA}CT NO. PROCESSED BY
License N LIc.Class�✓
Services,Swbd.,MCC 8 Psnelboerds DOp
Cortrecior Data 0-309 Amp.Under 900 V DAT F-
F-1400-1000 Amp.Under 900 V —/U' VALJDATION W
t em exempt under Sec. Over 1000 Amp.or Over 900 V
F7JAL !2
B.SP.C.for this reeaon BRANCH CIRCUIT FEES BY /f \
Date,
15A,or 20A,120V LIghtfng or Receipt. �•r� �S«.� Z
1 To 10 Branoh Clrc=uts
Sighature 11 To 40 Branch Clrafts
41Or Afore Branch CtrafM
❑ Eiiemption for Malnt Eject. 16A,MA,208V To 277V &.CYallis 2
SINGLE FAMILY Temp.Power Pole S Appurtenances1
HOME OVIINER-BUILDER DECLARATION Sign with One Branch CUcuh ACCT■T
I hereby affirm that I am exempt from the Contractor's Lloense Law {^� 197.19
for the following reason{Seotlon 7031.6, Business and Professions Addltlonal Sign Branoh Circuits 33ID7
Code): -
Mlao.Condults a Conductors 1 ITM
❑
I,as owner of the property,will do the work and the structure TryT�. 7 . 19
Is not Intended or offered for sale (Section 7044, Bualneee Other(See Complete Fee Schedule) , V
and Professions Code). CIEC 197.19
CONSTRUCTION LENDING AGENCY LdL4I� DO
I hereby atflrm that there Is a constructlon lending agency for the
performance of the work for which this permit Is Issued (Sec. 3097, PERMIT FEE (Sub-Total)
CIV.C.)
PLAN CHECFdNG FIE Woo—"i �i�/20/95
Lender's Nemo PERMIT ISSUING FEE p��/ �E3 1 AM11:56
Lenders Addreee
TOTAL FEE
I oertffy that I he"rend itla appkc±k n and under penalty of puIury state
that the above tnformation Is mTw;L I agree to comply with all County
ordVwK)o and State laws regulating E}edrical wiring,and hereby authotre
repreaentatfvee of dile County to enter upon the above-monlioned property
777� SEE REVERSE FOR EXPLANATORY LANGUAGE
apeNATUFE DATE