HomeMy Public PortalAbout6032 KAUFFMAN AVE_Electrical__ Wr?RKER'S COMPENSATION DECLARATION 9 DPW(12-91)
q% 76A6676A663 APPLICATION FOR ELECTRICAL PERMIT
I hemby afftm that:-I_have a certificate of consent to self insure,
or.a certlicate-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
C�v 3� �.
Certified copy is hereby furnished. New Residential Bldgs.&Poo «
.� � ADDRESS f/"NO. EACH FEE LOCALITY
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. — $ $ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools Y. 'ASSESSOR
��d S PAGE At'VZ C^SC/PARCEL
FIRM NAME 6
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rer�°� �"�-c ^M OWNER OR s-Ll_%
COMPENSATION INSURANCE
ff���� First 20 20 �/i MAIL
(This section need not be completed the work involved by the Total-176 EJP—I Additional ADDRESS
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY VL &4,_Vf 0 A&0 Tel.No.����1�
is issued, I shall not employ any person in any manner so as to PLAN CHECK V�+"
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date (� Applicant
NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. 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
p y Power Apparatus&Large Appliances APPLICANT QV�e- sre_ r-kdr0C„
provisions or this permit shall be deemed revoked.
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 OR �� i��® a
Over 50 to 100 Incl. REG.NUMBER 4Q. Class.
s �L.J C�® Over 100 DISTRICT NO. PR 'SSED BY O
License Number Lic.Class
Services,Swbd.,MCC&Panelboards � 9
���� �y �1� .� 0-399 Amp.Under 60f11L FINAL
Contractor ate DATE loi j J?�.9 C0❑ U 400-1000 Amp. Under 600 V / //
I am exempt under Sec. VALIDATION W
• Over 1000 Amp.or Over 600 V FINAL �n//J/f�.�y _� �
B.&P.C.for this reason BRANCH CIRCUIT FEES BY�./`rL%� `'� Cn
Date �y 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature �— 11 To 40 Branch Circuits
El Exemption
Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
i
SINGLE FAMILY Temp. Power Pole&Appurtenances Ht .i n 9
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law - - 7-4
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits '=U-' t`
Code): a 'TjLI'3
❑ Misc.Conduits&Conductors
I,as owner of the property,will do the work and the structure '�i�'L _ u -�
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) r
and Professions Code). CHECK
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 00 f-''1010 1
Lender's Name „/ D t i ?4 -71
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 inspec' puroOses.
' SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE F PERMITTEE DATE