HomeMy Public PortalAbout8919 HERMOSA DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ
I her affirm (jlat I have a certificate of consent to self insure, W6,4653
or a certificate of worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thererR(Sec. 3800 Lab.C.)
Policy N0• Company FOR APPLICANT TO FILL IN JOB
ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY TEMPLE Q_V
❑ 1&2-Family,Sq.Ft. OO $ $
Certified Copy is tiled with the county building Inspection ��n�'l -�T
department NEAREST
Multi-family Sq.FL CROSS Si. r//"" 6
Date Applicant Residential Swimming Pools ASSESSOR r1..� 1-L
MAP ROOK y PAGE e(�1k T PARCEL 02-0
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Red._Light Sw. OWN NAMEt!'7IA,
COMPENSATION INSURANCE
Additional
io MAIL " ` A I A D�
(This section need not be completed tf the work involved by the Total No. Atltlitional ADDRESS Nf A�
permit is for one hundred dollars(5100)or less.) �s�I pC
1 certify that in the performance of the work for which this permit CITY "TWE" TM.N N�)�/•OIpt7�
is issued, I shall 001 employ any person in any manner SD a5 to PLAN CHECK
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 Certificat= of CITY T.I.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 HERMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances APPLICANT Ou/
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I Hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Ind.(commencing with Section 7000) of Division 3 of the Business and CITY T.I.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl LICENSE OR }
Over 50 to 100 loci. REG.NUMBER Class. 0-
License
License Number Lid,Class Over 100 DISTRICT NO. q/ SSED BY Q
Services,Swbd.,MCC&Panelboards �Vcc
Contractor Date 0-399 Amp,Under 600 V FINALn�l O
❑ am exempt under Sec. 400-1000 Amp.Under 600 V N-/l� ~
!!!! VALIDATION U
Over 1000 Amp.or Over 600 V FINAL LU
8.&P.O for this reason BRANCH BY FEES BY
EL
In
Date: TEA,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 777V Lighting Br.Circuits
SINGLE FAMILY Tamp.Power Pole&Appurtenances H'_•�•1.s
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 77-113
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
C���oTTTnInlnlde): : ITE01'
LyJ 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) h_-.11 55-1,n Cc
and Professions Code). FIE F,)t A: 7°uj
CONSTRUCTION LENDING AGENCY C.( ANGE AID
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.) ia'llln-f')lj_ _if_�jl�U
PLAN CHECKING FEE _ -
Lender's Name '."PERMIT ISSUING ISSUING FEE Z
Lender's Address
I certify that atIhave read this application and under penalty of purjury state TOTAL FEE / 0
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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-20-�
SIGNAU OF PERMITTEE DATE