HomeMy Public PortalAbout6139 KAUFFMAN AVE_Electrical__ WORI!aSCOMPENSATIONDEGLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
76A663
.I hesebyraffirr>`i thatl have a certificate of consent to self insure,
or a certiftrcate of Worker's'.Corrmpen sation Insurance, orla certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.)
POlicy O. Company FOR APPLICANT TO FILL IN JOB X I
ADDRESS
Certified cop is hereby furnished. New Residential Bldgs.&Pools 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. 11101,
Date li Applicant Residential Swimming Pools ASSESSOR Q
MAP BOOK ��Q r� PAGE "717 PARCEL 4&4
CERTIFICATE OF EXEMP FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR
FIRM NAME
COMPENSATI INSURANCE `
First 20 MAIL
(This section need not be completed if the work involved by the ADDRESS
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 N .
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
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 7, S �/ -
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 / CTel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. !iSE OR >_
Over 50 t0 100 Incl. RIEG.NNUM ER Class. a
Over 100 DISTRICT NO. SSED BY O
License Number Lic.Class CIO y�� 0
Services,Swbd.,MCC&Panelboards !/ IY
Contractor;/ 'P S�/� •'�L FINAL
Date 0•399 Amp. Under 600 V DATE / O
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V S 1 y,� W
Over 1000 Amp.or Over 600 V FINAL a VALIDATION
B.&P,C.for this reason BY fn
BRANCH CIRCUIT FEES
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
SINGLE FAMILY Temp.Power Pole&AppurtenancessT �t �c
HOME OWNER-BUILDER DECLARATION { 3
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
Code):
❑
I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors =�LIj-%?f—'l�l�'1i 6/-2-117-5,
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , 1
and Professions Code). `i A') O,_,f
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) 0
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 1-f 6F
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE �� Q
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
c ��►- li
SIGN E OF PERMITTEE DATE