HomeMy Public PortalAbout5729 KAUFFMAN AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affiim 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 1 L./']!/(,.
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑
Certified copy is filed 1 &2-Family,Sq.Ft. $ $with the county building inspection NEAREST
department. Multi-family Sq. Ft. CROSS ST.
bate Applicant Residential Swimming Pools MAPEBOOK �y,F7 PAGE PARCEL�� 7
SSOR CERTIFICATE OF EXEMPTION FROM WORKERS' ER
Outlets:Rec.-3-Light AV Sw. ORM NAME 6-A
COMPENSATION INSURANCE First 20 '0O �O`
(This section need not be completed if the work involved by the ADDRESS ig
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY Tel.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 (?-AQAJ
Date���!// Q ////t I�11 ����.�s-,cam, Total No. Additional ADDRESS / A
-1�-t'3 Applic�tfit"'da& _ - S Z-- // - Q i v
RESIDENTIAL APPLIANCES NOT OVER 3 HP. Te o. 6
NOTICE TO APPLICANT: If, after making this Certificate of CITY ��� 6 t/�70
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions comply of the Labor Code, you must forthwith com I with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION '&Type HP,KW,KVA,or KVAR ADDRESS
ZI 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 OR `—^ >_
`s--^ Over 50 to 100 Incl. REG.NUMBER
S D6a--3 Class. a
License Numbery ��� Lic.Class Over-100 -_ DISTRICT NO. �f X/y PRO ED BY Q
Servic�wCC&Pa Iboaro/ •--� �5-� INALContractor Imo/b/(�1G/ir Date fS ` ` ` Rifp.`Under 660)0 DATE 0
❑ I am exempt under Sec. 400-1000 Amp_.lender 6r0
Over 1000 Amp.or Over 600 V FINAL VALIDATION
d
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
El
41 Or More Branch Circuits
Exemption for Reg. Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits 4
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit `
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ,S l 9'.2-YI
4
Code): TE!tF!
Misc.Conduits&Conductors
❑ �
I, as owner of the property,will do the work and the structure q� d�
is not intended or T offered for sale (Section 7044, Business Other(See Complete Fee Schedule) f,'g I AL•
and Professions Code). CHUCK 94.30
CONSTRUCTION LENDING AGENCY L¢l I
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 yfjlo 4-(ft 01 8/115 `f."•
Lender's Name
PERMIT ISSUING FEE It34 1 AM 7:55
Lender's Address
-1 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 ` OA
ordinances and State laws regulating Electrical wiring,and hereby authorize d
representatives of hi County to enter upon the above-mentioned property,
for insp s SEE REVERSE FOR EXPLANATORY LANGUAGE
S{ E DATE