HomeMy Public PortalAbout9564 LA ROSA DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm t`fiat I have a certificate of consent'to self Insure, 76A663 -
or a certlflcate 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 /�--
Certified copy 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
Date Applicant Residential Swimming Pools ASSESSOR &CC ' ('
MAP BOOK /moi PAGf�N PARCELdG
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR 7-
COMPENSATION INSURANCE Outlets Rec Light First 20 FIRM NAME
(This section need not be completed if the work Involved by the MAIL
permit is for one hundred dollars($100)or less) Total No Additional ADDRESS,
I certify that in the performance of the work for which this permit CITY Iq C," Tel Nogf,�41- 0
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 NOT OVER 3 HP
NOTICE TO APPLICANT If, after making this Certificate of RESIDENTIAL AANCES 0 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 suchPERMIT
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I h0eby 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
Over 50 to 100 Incl LICENSE REG NUMBER
Class
ER Q.
Over 100 DISTRICT NO PROCESSE O
License Number Llc Class _5
5.Servic �&PP,a{��IklaarCQ ®�
Contractor Date 39 mp"11nd091)V DATE FINAL O
❑ 400-1000 Amp Under 600 V
I am exempt under Sec ALIDATION
�Z W
Over 1000 Amp or Over 600 V FINAL V
d
B&P C for this reasonBRANCH CIRCUIT FEES BY U)
Date 15Q,or 20 20V i hU pyr pµepe Z
Signature 1 To Og9ra/bhUCi urts Q
11 To 0 Branch ircuits
El41 Or More Branch Circuits
Exemption for Reg Maint Elect 15A,20A,208V To 277V Lighting Br Circuits
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 �2
Code) ACCT.g
167
I,as owner of the property,will do the work and the structure Mlsc Conduits&Conductors 3303_ .50
s not Intended or offered for sale (Section 7044, Business the (S e Complete Fee S&hed-ulp .•?h�7 1 !
and Professions Code) 1 ITEMS
CONSTRUCTION LENDING AGENCY TOTAL :167 -50
I hereby affirm that there is a construction lending agency for the 167.50
performance of the work for which this permit Is Issued (Sec 3097, PERMIT FEE (Sub-Total) LD �tJE4I� 1f�, H C 1
Civ C)
PLAN CHECKING FEE CHANGE .00
Lender's Name
PERMIT ISSUING FEE ����y
Lender's Address r LJiJiJtl—��� �?,S�`�6
I certify that I have read this application and under penalty of purjury state TOTAL FEE �J� 6583 1 F'M 5o,g
that the above Information Is correct I agree to comply with all County O
ordinan sand State laws[e ulatIn Electrical wiring,and hereby authorize
rep sent Ives of this Cou y to enter upon the above-mentioned property
ins ction purp s SEE REVERSE FOR EXPLANATORY LANGUAGE
r
.� z3 7
\ SIGNATU OF P MI DAT