HomeMy Public PortalAbout10562 LIVE OAK AVE_Electrical__ y� WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 9•Y�����i`Y A B®�^ ®� ���A������ ������
76A663 �fl C �J
I hereby�ffirm tFil I have a certificate of consent to self Insure, '
or•a certlficzfte of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof•(Sec 3800 Lab C) Aa•T1oM4 4060IF/6V
PA WC4 A�105'A
Policy NO Company FOR APPLICANT TO FILL IN JOB J
ADDRESS
Certified co Is hereby furnished NO EACH FEE LOCALITY
PY Y New Residential Bldgs &Pools�� — $ , �D -
Certified co Is filed with the count building! on 1 &2-Family,Sq Ft .fi �'�
PY Y 9 NEAREST
dep ment Multi-family Sq Ft CROSS s7
Date :00-3 —Applicant '
Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF PTI FRO WORKERS' OWNER OR
COMP NSATION INSURANCE Outlets Rec —Light Sw FIRM NAME
MAI
(ThFirst 20 is section need not be completed if the work Involved by the Total No � Additional � ADDREssL � � /Q
permit Is for one hundred dollars(4100)or less)
I certify that in the performance of•the work for which this permit CITY Tel No
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 y� ) 1,,0V6provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT
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 Incl
(commencing with Section 7000) of Division 3 of the Business and CITY �® Tel No W
Professions Code,and my license is in full force and effect Over 10 to 50 Incl
LICENSE OR // Class
�/ --,, Over 50 t0 100 IDCI - REG NUMBER lD 4 Q a
License Number ��d`y 77 LIC Class Over 100 DISTRICT NO s�f� P�iyOyC/E'SS,ED BY O
`'d•e, /�� ? Services,Swbd,MCC&PanelboardsL'
Contractor(k -C�VF+/Y fDate J 0-399 Amp Under 600 V FINAL DATE O
❑ I am exempt under Sec 400-1000 Amp Under 600 V W
Over 1000 Am or Over 600 V VALIDATION
P FINAL Q.
B&P 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 Circuits
❑ 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 A .iT
8
I hereby affirm that I am exempt from the Contractor's License Law °•e
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits
3f`7 2ctrc
Code) Lr! .�-e
❑ I, as owner of the property,will do the work and the structure Mlsc Conduits&Conductors ^� !1 ITEM
i�
Is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TIJTAL ��m c
and Professions Code)
CONSTRUCTION LENDING AGENCY CHECK 250.65
1 hereby affirm that there is a construction lending agency for the CHANGE M
performance of the work for which this permit Is issued (Sec 3097, PERMIT FEE (Sub-Total) �a _. _
Civ C)
PLAN CHECKING FEE 0000-0001 3/19/$3
Lender's Name
PERMIT ISSUING FEE o� 878.4 1 AM 9:24
Lender's Address
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 erprupon the above-mentioned property
for inspect!qq,pur SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATOR OF PERMITTEE DATE