HomeMy Public PortalAbout4938 KAUFFMAN AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW 9/89 'A PP �C ' ION FOR EECTMI ALS I!✓LSWIItlaOII
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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.) ;I
Policy NO: Company FOR APPLICANT TO FILL IN- JOB
ADDRESS \� �^
Certified copy is hereby furnished. New Residential Bld s.&Pools EACH - NO. FEE tJ
g $ — $ LOCALITY ' 12 L •l - L ,9 0?0
❑' Certified copy'isfiled with`the co unty'building 'inspection 1 &2-Family,Sq.Ft. NEAREST
-,department. Multi-family Sq.Ft. CROSS ST.
Residential Swimming Pools - ASSESSOR
Date _ Applicant ! MAP BOOK -
., .�,e,• _ ,-. _ - _ _ PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR
FIRM NAME
COMPENSATION INSURANCE First 20
is section need not be completed if.the work involved by the -+ MAIL ADDRESS
permit is for one hundred dollars($100)or less) Total No. Additional
I certify that in the performance of th work for which this permit _ - -
CITY.- Tel.No.
is issued, I shall not em I r1;_any manner so as t0 PLAN CHECK
become subject to th - Lighting Fixtures First 20 - - APPLICANT
Total No. Additional ADDRESS
_qZr
Date ( Applicant > U1 , 150R 20A 120V BRANCH CIRCUITS
NOTICE TO APPLICANT:,If, after ma n t is Certificate of CITY Tel.No.
Exemption,•you should become subject to th orkers'Compensation 1 TO 10 INCLUSIVE EACH
rovisions of the Labor Code, you must forthwith comply with,such 11 TO 40'INCLUSIVE EACH- PERMIT / _C)LO ` , E uGra �i
P Y P Y, APPLICANT ly Y��sv �W+riK
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION - ADDRESS a2�2 -.LZ �, �u;CST d
I hereby affirm that Iam li'cen'sed under' rovisions of Cha ter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(comm ncing with Section 7000) of Division 3 of the Busine s and __• _ __. CITY _"At C C CQ(ir,2. Tel.No.gtnkko-O�G 0
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE ORE�f yS y� 1 n cc
Power Apparatus&Large Appliances REG.NUMBER J "l U Class. C l V O
License Number Lic.Class CA b Size'&Type HP,KW,KVA,or KVAR DISTRICT NO. P C SED BY
-Up-to 3'lnc1• _ _ /tr - W
oLae� 6-S-K ( /Qte�T�,�_C� Over 3 t0 10 Incl. FINAL d
Contractor Date vn^ _.__ _ _ DATE Z
❑ -- - - • � • ' OveCD
r 10 to 50 Incl--.
I am exempt under Sec. Over 50 to 100 Incl. ; VALIDATION Z
FIN
B.&P.C.for this reason - Over 100 AL
L -- - _ FIN
j Services,Swbd.,MCC-&Panelboards
Date:i�LK�` _'I�t 0-200 Amp.Under 600 V
201•-1000 Amp.Under 600 V .-
_ Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.M .Elect. - - -----•-- -- -.- --- - -
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION -- -- --' ar•: s
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 _. _ _3 t-' 59.5-_1,
Code): `_.i :/'ii . 7 a-3•_
❑ Misc.Conduits&Conductors- - - - - t T s I�
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) +• 59- 55
= a-. E
and Professions Code). _ . - •. _ _ _ )I i! __n9® _s_E
CONSTRUCTION LENDING AGENCY ry� c�
_6
_i a_i
I hereby affirm that there is a construction lending agency for thek��q ssGL .00
performance of the work for which this permit is issued (Sec. 3097, PERMIT-FEE -_- _ -i - -(Sub-Total) i tE9 3i»
Civ.C.)
PLAN CHECKING FEE
Lender's Name - 1 Ij_;)1i 1 0Off0 1 +2
PERMIT ISSUING FEE a"7/ r•i F
'
Lender's Address
1 certify that I have read this application and state that the above TOTAL FEED_ 1 AM ar.
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
SIGNATURE OF APPLICANT OR AGENT DATE