HomeMy Public PortalAbout10560 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 76A669 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
76A663 Ij'� �+'
I hereby,affirnt that I have a certificate of consent to self insure,
or a certifiEate of Worker's Compensation In urance, or certif;ed COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab.fC1q) A/Q7 /
Policy No( Lom an /v '7 1Qi[ FOR APPLICANT TO FILL IN AD
y p yr4�f'�,- ADDRESS
❑ r Certified is copy y rnished New Residential Bldgs &Pools
_ herebfur g NO EACH FEE LOCALITY
�• Certified copy is filed with the county building Inspection 1&2-Family,Sq Ft v� _ $ lin $ NEAREST
depa ment Multi-family Sq Ft CROSS ST
Date3A fai AS Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL y
„CERT.IFICATE OF EX TION FROM WORKERS' Outlets Rec LI ht Sw OWNEROR ME �� v
9 FIRM NAME /WG?,
COMPENSATION INSURANCE -
First 20 MAIL c
(This section need not be completed If the work Involved by the Total No Additional ADDRESS�/ G.J-
permit is for one hundred dollars($100)or less)
I certify that in the performance of the work for which this permit CITY Tel No l
is issued, I shall n_ot employ ariy 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 i -
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 / NC�
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANTAJ L.!
! LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR, _ ADDRESS C. -;5WA416,
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 ,�IrNTE Tel No e
Over 10 to 50 Incl
Professions Code,and my license is in full force and effect LICENSE ORQ }
Over 50 to 100 Incl REG NUMBER-� 4/,77Class
License Number ✓G � 7� Lic Class �y Over 100 DISTRICT NO 10C SED By O
Services,Swbd,MCC&Panelboardsacc
1,9%1-l1AW�Date 3/ 0-399 Amp Under 600 V FINAL 0
Contractor DATE
❑ 400-1000 Amp Under 600 V
1 am exempt under Sec VALIDATION V
Over 1000 Amp or Over 600 VFINAL d
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 CrCUIt,
❑ 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 Sign with One Branch Circuit ACCTa
I hereby affirm that I am exempt from the Contractor's License.Law n8
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits - - �07 pry '6
Code) i ITEM �tiy
❑ I,as owner of the property,will do the work and the structure Misc Conduits&Conductors i ITE I,7
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D TOTAL250-65
and Professions Code) ry
CONSTRUCTION LENDING AGENCY CHECK ,2 0.65
1 hereby affirm that there is a construction lending agency for the CHANE .00
performance of the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub-Total)
Civ C)
PLAN CHECKING FEE
Lender's Name O0OW— i 3/19/93
PERMIT ISSUING FEE n,
8.78: 1 AM 9:24
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE �Q.
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 urp s 4 SEE REVERSE FOR EXPLANATORY LANGUAGE
GNU O RM DATE