HomeMy Public PortalAbout4836 HALLOWELL AVE_Electrical__ J WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT LLLJJJ
I hereby tfirm that I 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.)
Policy No. Company \ '"� FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO, EACH FEE
$ $ LOCALITY
1 &2-Family,Sq. Ft. O
_
Certified copy is filed with the county building inspection -. ., NEAREST
department. Multi-family Sq. Ft. } CROSS ST.
Date Applicant Residential Swimming Pools ASS BOOK
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. OWNER OR
NAMEFIRM
�.
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY Tel.Nob{ . es �
is issued, I shall not employ any person in any manner so as to PLAN CHECK 1 OCA'
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant — RESIDENTIAL APPLIANCES NOT OVER.3 HP.
NOTICE TO APPLICANT: If, after making this 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 APPLICANT (�
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 3 (�P Over 3 to 10 Incl. /
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE R
Over 50 t0 100 Incl. REG.NUMBER :5C-)(SSU Class. 2•Q CL
Over 100 DISTRICT NO. PRPC SED BY O
License Number r-����6� Lic.Class 2 e� U
1 Q Services,Swbd.,MCC&Panelboards �/ G L��i��FINAL O
Contractor Date`Z�2 t 3 t,. $OA•"Amp.Under 600 V DATE `� H
El
400-1000 Amp.Under 600 V /� U
I am exempt under Sec. VALIDATION uj
Over 1000 Amp.or Over 600 V FINAL OJ a.
B.&P.C.for this reason BRANCH CIRCUIT FEES BY U)
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances a
HOME OWNER-BUILDER DECLARATION `-'`-;
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit _
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits -'1_2
-� • =(E
Code): 1 ITEMS
❑ 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors f
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I1-f T` L 32 = 20
and Professions Code). �`r';'•1`
-FIL::fi
CONSTRUCTION LENDING AGENCY 'H_W:E
I hereby affirm that there is a construction lending agency for the ^
performance of the work for which this-permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.) I t 3 .1n-
PLAN CHECKING FEE .�"''-��-t�-I� �,-.`=: �%
Lender's Namen/ .;^!
PERMIT ISSUING FEE �(fj ^0 `r1' '1=
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE a• (/(/
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 ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Z _zg� 3
SIGNAIURE OF PERMITTEE DATE