HomeMy Public PortalAbout10556 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPUC p/L�TION FOR ELECTRICAL p L PERMIT
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I heieby affirm t11at I have a certificate of consent to self Insure,
or a ceftificate of Worker's Compensation Insurance, or a celtified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 ab ) N+4TI4W&1*nA&' ' «
Awry�oid�6�, /
Policy Nd� Company / FOR APPLICANT TO FILL IN JOB
ADDRESS 1,0145'
Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE LOCALITY cam'
1&2-Family,Scl Ft -=�
Certified copy is filed with the county buildin insp cti — NEAREST 41
.department Multi-family Sol Ft CROSS ST
Date 'L—,Applicant Residential Swimming Pools rASSESSOR,
-" 'MAP BOOK PAGE 4— PARCEL ZYY
CERTIFICATE OF E RM WORKERS'
-- PTIOOOutlets Rec _Light Sw }
OWNER
NAME / `N
COMPENSATION INSURANCE — -
i , First 20 MAIL
(This section`ri not be completed if the work Involved by the Total No Additional ADDRESS O! 0,0 # e��
permit is for one hundred dollars($100)or less)
I certify that in the performance of the work for which this permit CITY A Tel No�J/n
Is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject io the'Workers'Compensation Laws Lighting Fixtures First 20 APPLICANT
Total No Additional
• '- ADDRESS -
Date Applicant e
RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTIC-E 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 /
�ovisions of the-Labor Code, you' must forthwith com I with such PERMIT �C
P Y P Y APPLICANT `
provisions'or this permit shall be deemed revoked - Power Apparatus&Large Appliances �f
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 Inclr
(commencing with Section 7000) of Division 3 of the Business and CITY14-
6417 Tel No�+fj {3
Professions Code,and my license is in full force and effect
Over 10 to 50 Incl �Go
LICENSE �jd 7 Class
'
Over 50 t0 100 Incl REG NUMBER
License Number n-
�10 �-7 Lic Class Over 100 DISTRICT NO PROCESSED BY - O
L
Services,'Swbd,,MCC&Panelboards �O cc
GH(�.�/V/` �, 0-399 Amp Under 600 V FINAL O
Contractor Date DATE
Elm 400-1000 Amp Under 600 V ^` VALIDATION V
I aexempt under Sec Over 1000 Amp or Over 600 V FINAL CL
B&P C for this-reason- BRANCH CIRCUIT FEES BY W
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 Mainf Elect 15A,20A,208V To 277V Lighting Br Circuits
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Temp iP One Branch ppurtercuit tt �'T .JL
I hereby affirm that I am exempt from the Contractor's License Law AC i na
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits -- �1 L
9
Code) �SJreUf
I, as owner of the property,will do the work and the structure Misc Conduits&Conductors il ITEMSi�
is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) - TOTAL 288® 9Ji d�
and Professions Code)
x
CONSTRUCTION LENDING AGENCY
C�ECK 288.09
I hereby affirm that there is a construction lending agency for the -CHANE a0
performance of the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub-Total)
Civ C) -
PLAN CHECKING FEE
Lender's Name DO(D-0001 3/19/93
'
PERMIT ISSUING FEE - — ' -$779 1 AM 9:23
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE617
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 pur s l / SEE REVERSE FOR EXPLANATORY LANGUAGE
IS
TUR OF PER E DATE -