HomeMy Public PortalAbout10552 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APP1l..�C9' TMN FOR ELECT MCAD PERNT
I tipreby affirm that I have a certificate of consent to self Insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof'(Sec 3800 b C)
Policy No RA od Company ./ Co V
y/YS, FOR APPLICANT TO FILL IN JOB
ADDRESS
El • Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE _
— LOCALITY
ur
Certified copy is filed with the county buildin spe do 1 &2-Family,Sq Ft ?� — $ �d $ � NEAREST
department Multi-family Sq Ft CROSS ST /U
Date Appllcan Residential Swimming Pools ASSESSOR ?f
•MAP BOOK PAGE �y PARCEL
CERTIFICATE OFPTION OM WORKERS' Outlets Rec _Light Sw OWNER OR
COMPENSATION INSURANCE FIPM NAME j" Sl
Nrl_ /SFV, IAA::!-.
First 20 MAIL
(This section need not be completed if the work Involved by the Total No Additional ^A /fin
ADDRESS IGU �Tpj �–
permit is for one hundred dollars($100)or less)
I certify that In the performance of the work for which this permit CITY L Tel No 11j /
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 Alal .IA
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 14W?y
LK AvE
I hereby'afflrm'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 �L MQA(/� Tel No
Professions Code, and my license is in full force and effect Over 10 to 50 Incl
LICENSE OR ' Class �e }
e. /' Over 50 t0 100 Ind L77
NUMBER D 7 Ci�D a
License Number 7�a`Y`77 LIC Class _/V Over 100 DISTRICT NO" PRO�Y
//// Services,Swbd,MCC&Panelboards
�
Contractor IFN 6WA Date 3� 0-399 Amp Under 600 V FINAL O
DATE 0
El I am exempt under Sec 400-1000 Amp Under 600 V
i VALIDATION V
Over 1000 Amp or Over 600 V FINAL LU
B&P C for this reason BRANCH CIRCUIT FEES BY
U)
Date 15A,or 20A, 120V,Lighting or Recept Z_
1 To 10 Branch Circ
wts
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 2
HOME OWNER-BUILDER DECLARATION t rc
Sign with One Branch Circuit I
I hereby affirm that I am exempt from the Contractor's License Law SigACCT,
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits
Code) 33107
2 28°,.0:.
❑ 1,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) � t
.o_ q�
and Professions Code) D TOTAL� ® !'y
CONSTRUCTION LENDING AGENCY J CHECK 238.09
1 hereby affirm that there is a construction lending agency for the �.�ftf�iVG
performance of the work for which this permit Is Issued (Sec 3097, PERMIT FEE (Sub-Total) 6E .�I�E�d. tiff
Civ C)
PLAN CHECKING FEE t GOD-0031 ,3/19/9
Lender's Name
Lender's Address �
PERMIT ISSUING FEE �–S
8'7° 1 AIS 9=2
I certify that I have read this application and under penalty of purjury state TOTAL FEEthat 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 ur oses SEE REVERSE FOR EXPLANATORY LANGUAGE
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SI ATU ER DATE