HomeMy Public PortalAbout9432 LAS TUNAS DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby 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 WORKSBI'.IL G F}D1D SAFETY DIV.
t4 7
copy thereof(Sec. 3800 Lab. C.) , 3, I--
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Policy NO. Company FOR APPLICANT TO FILL IN JOB ADDRESS `�1, � �,�QS �(Q(�► ` y'
Certified copy is hereby furnished. New•Residential Bld s.&Pools NO. EACH FEE h
Bldgs. LOCALITY em ArLL 41 _L V
Certified co Is filed with the count building inspection 4 &2-Family,Sq.Ft. — $ $
❑, PY Y 9 P — NEAREST
department. Multi-family Sq.Ft. CROSS ST. CA V� 4t.
Date - Applicant Residential Swimming Pools ASSESSOR
MAP BOOKPAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS'. Outlets:Rec._Light Svv. FIRM NAME t }
COMPENSATION INSURANCE �'l Y _� �' `,
First 20 •MAIL
(This section need"not be`completed if the work involved by the ADDRESS ` t
permit'is for one hundred dollars($100)or less.) Total No. Additional
I certify'that in the performance of t for hich this ermit CITY III, L—C T a
is issued, I shall not employ any'p rson in any anner s as to PLAN CHECK
become.subject to the Workers'Com nsa' Law Lighting Fixtures First 20 APPLICANT
Total No. Additional
Q ADDRESS
Date •I r 'Applicant ' RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE-TO APPLICANT: If, ter mak this Certificate of CITY Tel.No.
Exemption,you should become subject,to t Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you'must fo with comply with such PERMIT i
P P.Y Power Apparatus&Large Appliances APPLICANT �l bf eV d f,/1�1(M,N
provisions or permit shall be deemed rev ked. ' �-
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS � �j r '
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.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSEClass. a
Over SO to.100 Incl. REG.NUMBB ER
Over 100 DISTRICT NO. PR C SED BY. 0
License Number Lia Class
Services,Swbd.,MCC&Panelboards "4,1P/ cc
0-399 Amp.Under 600 V 2 FINAL O
.Contractor Date. DATE _
❑ - 400-1000 Amp.Under 600 V �� V
lam exempt under Sec. VALIDATION LU.
Over 1000 Amp.or Over 600 V FINAL �
B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z
Date: 15A,or 20A, 120V,Lighting or.Recept
1 To 10 Branch Circuits
Signature 11.To 40 Branch Circuits 6
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 i
HOME OWNER-BUILDER DECLARATION. i ........ ...
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit A 'i °a
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits -7 2 s• cc
Code): 330, � :o•_
❑ I,as owner of the property,will do the vvork and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section,7044, Business Other(See Complete Fee Schedule) TOT A
and Professions Code). .•., 233.55 x3 _5
CONSTRUCTION LENDING AGENCY _��l,
I hereby.affirm that there is a construction lending agency for the -CHANGE _ °00
performance'of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE t?;LI fYLIO1 1/15/93
Lender's Name _� -. j °(tC
PERMIT ISSUING FEE t_
r 41 1 :t1 ' ° '-
Lender's Address
I certify t at I have read this application and under penalty of purjury state TOTAL FEE `L, j
that t abo information is correct. I agree to comply with all County
ordinE ices an State a ating Electrical wiring,and hereby authorize
repre ntat s thi Coun o enter upon the above-mentioned property
for in Ion p pos s. SEE REVERSE FOR EXPLANATORY LANGUAGE
CUW i f �PC?
IGNATURE O PER ITTEE DATE -