HomeMy Public PortalAbout6251 IVAR AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) /WPIT1��CA 11 �®N FOR EL ECTMICAL PER ISI T
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I hereby affirm that I rave 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 hereof(Se�c.§3�8800Lab.:C.) a
.Policy�No.1®'r/&6 Company 4-$ ',, `�W� FOR APPLICANT,TO FILL IN AD
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE r r f
❑ ent _ $ $ LOCALITY �/Y�� �� 4Y 7-V
Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. — NEAREST
department. Multi-family Sq.Ft. CROSS ST. Z_0A., 45WA--,
Date Applicant `s Residential Swimming Pools ASSESSOR
MAP BOOK _' PAGE PARCEL®0
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR y�
COMPENSATION INSURANCE. Outlets:Rec._Light Sw. FIRM NAME
First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS S�
permit is for one hundred dollars(5100)or less.)
I certify that in the performance of the work for which this permit CITY ��rZ'/�IL� Garp TeI.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
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
APPLICANT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances `7"•
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS/,60.?,J_ 5-1+A1�,Cl2glI i
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 fie//ry//s� rel.No.9'(;��
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. If—
f f }
Over 50 t0 100 Incl. REGNNUM ER �� �// Class. d.
License Number 91614-11 LIC.Class 10S Over 100 DISTRICT NO. p PR C SED BY O
_ Services,Swbd.,MCC&Panelboards �O
Contractor °J ► � " �Date 0-399 Amp.Under 600 V FINAL O
DATE
❑ 400-1000 Amp.Under 600 V -�s VALIDATION V
1 am exempt under Sec. W
Over 1000 Amp.or Over 600 V FINAL a-
B.&P.C.for this reason BRANCH CIRCUIT FEES BY 1 /
Date: 15A:or 20A,120V,Lighting or Recept. z"(�J( _
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F-141 Or More Branch Circuits
Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits71- ACCT.
r£
SINGLE FAMILY ACC'Teg
Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit 33 3 p V
I hereby affirm that I am exempt from the Contractor's License Law ,�,��,j '� +(} `�~
a.V v a.'J
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits t-l�l '
Code): 1 .ITC! S
EJ property, Misc.Conduits&Conductors TOTAL 28 x. 2
I,as owner of thewill do the work and the structure � o a....
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D CHECK 294.21
and Professions Code). r
CONSTRUCTION LENDING AGENCY CHANGE "00
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.) 0000-0001 17/ 7/95
Lender's Name PLAN CHECKING FEE 3640 1 AN10'.15
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
representatives of this County to enter upon the above-mentioned property
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-7a-
-SIGNATURE OF PERMITTEE DATE