HomeMy Public PortalAbout10548 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 LK PPUCL'' TION FOR ELECTMA L PERNT
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heret;y affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensate n Inn�ranfie,9r a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof r�(,,rSr,e�cg 38A00 Lab
C) Xf �(/ �lerr 1C4A-
WGT OV l�"�_� FOR APPLICANT TO FILL IN JOB 'b 1 (u pow
P❑ol cy No ompany /� - w l_ po
�— ADDRESS
Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE
$ $ LOCALITY E c Q j S J
Certified co is filed with the count buildin ins 1 &2-Family,Sq Ft
department y g pe n Multi-family Sq Ft CR ST EL Q/V'T�
Residential Swimmmg Pools • ASSESSOR
Date Applicant MAP BOOK &fffg I PAGE PARCEL ZZ
CERTIFICATE OF EXE4PTION FROM WORKERS' Outlets Rec —Light Sw OWNER OR .�•
COMPENSATION INSURANCE g FIPM NAME /Q/S, /1/7— �(/, IA/G-
Flrst 20 MAIL p^
Thissection need not be completed if the work involved b the
permit is•fo' p
r one hundred dollars($100)or less.) y Total No Additional ADDRESS
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
r 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 , / i 1 /N e
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances, APPLICANT /V L/ / (s
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I tiereby 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 �� 'Erz �,4/7i5 Tel Nock?'�iJ/gsj
Professions Code,and my license is in full force and effect Over 10 to 50 Incl OR ^
Over 50 to 100 Incl REG NNUMBER (0 7� Class C�0
5 / }
i Q�
0-
License
License Number S`lD0-17 Lic Class C-1 a Over 100 DISTRICT NO
Services,Swbd,MCC&Panelboards D
It
L'/�/��C�(/�/{I+ � 0-399 Amp Under 600 V FINAL 0
Contractor Date DATE Q7
❑ 400-1000 Amp Under 600 V r J
I am exempt under Sec VALIDATION V
Over 1000 Amp'or Over 600 V FINAL- W
B&P C for this reasonBRANCH 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
SINGLE FAMILY Temp Power Pole&Appurtenances +
HOME OWNER-BUILDER DECLARATION n with One Branch Circuit A�`�
I hereby affirm that I am exempt from the Contractor's License Law SigoT"
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits — --
Code) 3607 250a6=
El1,as owner of the property,will do the work and the structure Misc Conduits&Conductors 1 ITEMS
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code) D FTOTAL —250- 65
�e
CONSTRUCTION LENDING AGENCY �'t1�,��,`Lp,.K 250.65
I hereby affirm that there'is a construction lending agency for the t�t,l'lNGE N oLQ
performance of the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub-Total) '
Civ C)
Lender's Name PLAN CHECKING FEE OOOCI-0001 3/19/93
PERMIT ISSUING FEE - -
IS7�1
Lender's Address '�3
1 AM9
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 inspection p oses SEE REVERSE FOR EXPLANATORY LANGUAGE
NATU LTTE DATE