HomeMy Public PortalAbout5918 IVAR AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION n FOR ELECTRICALLL PERMIT
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I hereby affirm that I have a certificate of consent to self insure, 76A663
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.,3,800 Lab.%C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB - i$ J)VIE
❑ J'I VIE
Certified copy is hereby furnished. New Residential Bldgs,&Pools NO. . EACH FEE.. ADDRESS �J,
❑ _ $ $ LOCALITY
Certified co Is filed with the count building inspection 1 &2-Family,Sq.Ft.
Py y 9. p � NEAREST
department. Multi-family Sq.Ft,, — CROSS ST.
Date" Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL-
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR , c LEJ; / 'LEE ti
COMPENSATION INSURANCE Outlets:Rec._Light SW. FIRM NAME L E
First 20 MAIL / / 1 T 11 M I
(This section need not be completed if the work involved by the, ADDRESS 7 1.V/ Z v
permit is for one hundred dollars($100)or less.) Total No. Additional A C� 0�
I certify that'in the performance of the work for which this permit CITY TEM PLS Cif el.No.
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
_ Total No. Additional
ADDRESS
Dat
/F (J it 1 I .X�e Applicant L' caT RESIDENTIAL APPLIANCES NOT OVER 3 HP.
X NOTICE 0 PPLICANT:;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 � � 6��
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."
Over 50 to 100 Incl. LICENSE
REG.NUMBER
ER Class. a
License Number Lic.Class Over 100 DISTRICT NO. �R�O�ESSED BY 0
�Service Swbd.,MCC&PaJfJ�IJo�(N� l
m Qel'EiUU o' / GFINAL 0
Contractor Date ' DATE
❑ I am exempt under Sec. Cr mp. nder 600 V _��� 0
VALIDATION V
er 1000 Amp.or Over 600 V FINAL - d
B.&P.C.for this reasonBRANCH 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,2DA,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp. Power Pole&Appurtenances >`•r � �
HOMEOWNER-BUILDER DECLARATION ITE i'.r
e 4E
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 65 MM3
'` Code):
I,as owner Misc.Conduits&Conductors of the property,will do the work and the structure f�•�t;=yr:;r. _j
�\ is not intended or offered for sale (Section 7044,•Business Other(See Complete Fee Schedule) I r t+ r1V
1 and Professions Code). i if-fill
CONSTRUCTION LENDING AGENCY
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.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
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
,apresentativ S of this County to enter upon the above- entioned property
io
rinspectiI pur seSEE REVERSE FOR EXPLANATORY LANGUAGE
TIGN TA UR ERMITTEE 1 DATE -