HomeMy Public PortalAbout10550 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 �Jj Q PPUCATI®N FOR ELECT AL PERNT
a �J
I here`s,,aE 't�at I have a certificate of consent to self Insure,
or a certificate oof�Worker'ss/Compensation I surance,pr �certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(��c 3�O,LadJ4 V/fig{•Y1��YJa„(Ql /nel�CQ�t�
�Cy No PX COmp�ny 4IS 4 4:740, FOR APPLICANT TO FILL IN JOB �v p
ADDRESS
Certified copy is hereby furnished New Residential Bidgs &Pools NO EACH FEE
$ $ LOCALITY (�� CIT
Certified co Is filed with the count building Ins ectl 1 &2-Family,Sq Ft
PY Y 9 P — NEAREST
dep rtme t Multi-family Sq Ft CROSS ST G
Date at., Applica Residential Swimming Pools ASSESSOR �j/
_ MAP BOOK PAGE PARCEL 7�
CERTIFICATE OF EMPTION FROM WORKERS' Outlets Rec —Light Sw t FIRM
MAIL
NAME
COMPENSATION`INSURANCE First r
FIfSf 20 MAIL
(This section need not be completed If the work Involved by the Total No Additional ADDRESS s, E
permit Is for one huridred dollars($100)or less.) '
I certify that In the performance of the work for which this permit CITY A Tel No
is issued, I shall not employ any person In any manner so as to
become subject to the Workers'Compensation Laws Lighting Fixtures First 20 PLAN CHECK
J p 9 APPLICANT•'
Total NoAdditional
• 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 _Ab�U WC
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS O`o ,L /✓J
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 ,` >_�1 Over 50 to 100 Incl REG NNUM ER �l0 447 Class // O a
License Number ¢io47� Lic Class c��
Over 100 DISTRICT NO PROCESSED (i
Services,Swbd,MCC&Panelboards
Contractor L H��+��ys�° Date 0-399 Amp Under 600 V FINAL O
DATE
❑ I am exempt under Sec 400-1000 Amp Under 600 V — /,l w
Over 1000 Am or Over 600 V ! VALIDATION
P FINAL 101-
B
lB&P C for this reason BRANCH CIRCUIT FEES BY (n
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 Red Mamt Elect 15A,20A,208V To 277V Lighting Br Clrcwts
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
08
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits
Code) 33307 243.9
LI
❑ I, as owner of the property,will do the work and the structure Misc Conduits&Conductors "1”-ITEM
Is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL
and Professions Code) i 1 I_I I AL/ 2-43. 90
CONSTRUCTION LENDING AGENCY CHECK 2Y 3.1 0
1 hereby affirm that there is a construction lending agency for the fLIwI' ��''rr
performance of the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub-Total) �� CHANGE .Lttl
Civ C)
PLAN CHECKING FEE
Lender's Name 0000-13001 '3/119/91-iPERMIT ISSUING FEE �(� qk
Lender's Address '�—�' 80 1 AM 9o+'3.
I certify that I have read this application and under penalty of purlury 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 u on the above-mentioned property
for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF P E DATE -