HomeMy Public PortalAbout9948 HOWLAND DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) �
76A663 APPLICATION. FOR ELECTRICAL PERMIT �f
I hereby affirm 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
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Poyl`s� NO. EACH FEE LOCALITY �� 1
1&2-Family,Sq.Ft. by I � — $^ $
Certified copy is filed with the county building inspection _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR o
MAP BOOK ' PAGE,00 4(' PARCEL Qd-7
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR
COMPENSATION INSURANCE g FIP.M NAME t� e. !y7
(This section need not be completed First 20 MAIL
the work involved by the Total No. Additional ADDRESS 3
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY ��. Tel.Nft
is issued, I shall not employ any person in any manner so as t0 elee
PLAN CHECK
become subject to the Workers'.Com pen sation 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
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
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 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 ORClass. }
Over50 t0 100 Incl. REG.NUMBB ERa
License Number Lic.CIBSS Over 100 DISTRICT NO. PROC SSED BY O
Services,Swbd.,MCC&Panelboards ✓ y �LLrr✓r�_, cc
0-399 Amp.Under 600 V FINAL 0
Contractor Date DATE
El
400-1000 Amp. Under 600 V 3 VALIDATION U
I am exempt under Sec.
Over 1000 Amp.or Over 600 V FINAL W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature
11 To 40 Branch Circuits + 5
❑ 41 Or More Branch Circuits -p
Exemption for Reg.Maint.Elect, 15A,20A,208V To 277V Lighting Br.Circuits 2
SINGLE FAMILY Temp.Power Pole&Appurtenances A:CT.a
HOME OWNER-BUILDER DECLARATION - ,- -! ��7 r^
1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
3i� f �}s
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits - y t-nl `
Code): s I Fl.w
___.. _
TA
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors s AL _5_57- 95
I-I t
s not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) C _�;Q 7J
and Professions Code).
o
CONSTRUCTION LENDING AGENCY CHANGE DID.
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) / : 1313030_01001 11/ 6.1/i
Civ. C.)
PLAN CHECKING FEE 1 u d ;i-
Lender's Name ,*
Z 4,J44.
PERMIT ISSUING FEE Y75
Lender's Address At/A
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 nter upon the above-mentioned property
for inspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE PER EE DATE •