HomeMy Public PortalAbout10558 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I I
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I hereby affirm thatI have a certificate of consent to'self Insure, ;
or a certificate Sf'Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof
ec 3800 C JO
Policy N /`•."
�^ Company
�DD����� FOR APPLICANT TO FILL IN ADDRESS
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Celrtl6ed copy is hereby'funmsf edNew Residential Bldgs &Pools NO EACH--,
$ $ LOCALITY Com!
Certified co is filed with the count building Ins ctlon 1&2-Family,Sq Ft f��
PY Y 9 P NEAREST
department Multi-family Sq Ft CROSS ST r
Date Applican Residential Swimming Pools -� 'ASSESSOR Q/ a
'MAP BOOK a6{7 PAGE i«n PARCEL31
CERTIFICATE OF MPTION FROM WORKERS' Outlets Rec Light Sw OWNER M ""��
COMPENSATION INSURANCE g First 20 PIPM-NAE(J��S /A/7 , ?WC
(This section need not be completed it the work Involved by the ADDRESS 5?
permit is for one hundred dollars($100)or less) Total No Additional
I cerUfy 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 t0 'PLAN CHECK'
become subject to the Workers'Compensation Laws Lighting Fixtures First 20 APPLICANT
Total No Additional
ADDRESS
Date Applicant
NOTICE,TO APPLICANT If, after making this Certificate of RESDENTIAL,APPLIANCES NOT OVER 3HP 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 APPLICANT
provisions or this permit,shall.be deemed revoked Power Apparatus&Large Appliances C.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS,
I ffirm 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�� �r�
Professions Code, and my license Is in full force and effect Over 10 to 50•lncl OR
Over 50 to 100 Incl LICESE REG NNUMBER 5`l0 4Z77 Class C/10 }'
CL
rl��T7 �0 - Over 100 M DISTRICT NO PROCESSED BY O
License Number Lic Class 0
�',t/ .I' Services,Swbd,MCC&Panelboards Cc
ContractoM'fN � Date �� 0-393 Amp Under 600 V DATE
❑ -'-•"I am"ex-emptunder- -Sec- 400-1000•Am Under 600 V Gt
VALIDATION - V
Over 1000 Amp or Over 600 V FINAL _ LU
BAP C for this reason' BRANCH CIRCUIT FEES BY
Date 15A,or 20A,120V,Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To,40 Branch Circwts
41 Or More Branch Circuits f
❑ •Exemptio_n for Reg fdlaint Elect 15A,20A,208V To 277V Lighting Br Circuits r '�
SINGLE FAMILY Temp Power Pole&Appurtenances -
ANTAr
r • -
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � �+° (
I'hereby affirm that I am exempt from the Contractor's License Law �s07
for the'following reason (Section 7031 5,•Business and Professions - Additional Sign Branch Circuits
Code) 1 ITEM
Misc Conduits&Conductors " ` -" - — �• i;y31 '�1 •'�°
!, as owner of the property,will do the work and the structure I(�TtiL +.-"�"+=1' ® 90
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code) �` CHECK
243.51 E
CONSTRUCTION LENDING AGENCY _ Y CHANGE' °)O
I hereby affirm that there is a construction lending agency for the -
performance of the work for which this permit Is issued (Sec 3097, PERMIT FEE (Sub-Total) _L
Civ C) 0000-0001 3/19 /i
PLAN CHECKING FEE
____--_--. - tNt 1 Ol° i
Lender's Name
PERMIT ISSUING FEE
Lender's Address A
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 rp0 SEE REVERSE FOR EXPLANATORY LANGUAGE
IG RE EE DATE _