HomeMy Public PortalAbout9422 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT
I,$ereby afM'rm 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 WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS G
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ _ $ $ LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST
department. Multi-family Sq.Ft. — CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRMNAMEAME ,�/fj
COMPENSATION INSURANCE First 20 / /�
(This section need not be completed if the work Involved by the MAIL
,7 �/ VG d6Y�/ �trtI
permit is for one hundred dollars($100)or less.) Total No. Additional G 2
I certify that in the performance of the work for which this permit CITY 7e^4 at.No.
is issued, I shall not employ any person in any man r so as to PLAN CHECK
become subject to the Workers'Compensatio Laws. Lighting Fixtures First 20 APPLICANT
' ; Total No, Additional ADDRESS
Date Applicant i
NOTICE TO APPLICANT: If, after m g t i Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No.
Exemption,you should become subject to the Wo kers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT L
Appliances APPLICANT
A
Apparatus&Large pp
provisions or this permit shall be deemed revoked. Power Appa
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS �� 'e7� C���,Z eve
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl. CITY &, /"0" / Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSE OR /' Class. C f Q
Over 50 to 100 Incl. REG.NUMBER & J (�
Over 100 DISTRICT NO. P SSED BY
License Number `�C Lic.Class Q V
- Services,Swbd.,MC Panel oard �/!/
n �gS � -h/cea-� Services,
Swbd., NAL O
FI
Contractor x/'� Date ���/ 399 r L.1 d DATE
❑ 400-100 Amp.Under 600 V ` VALIDATION V
I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL y W
B.&P.C.for this reasonBRANCH CIRCUIT FEES eY
D e: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F-141 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits }
SINGLE FAMILY Temp. Power Pole&Appurtenances ACCT.T
HOME OWNER-BUILDER DECLARATION n Sigwith One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law 3303 65.60
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 1 ITEM
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 65.60
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). , CHECK �`*��
CONSTRUCTION LENDING AGENCY CSE ■00
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) Woo-.0001 ff L /pt
Civ.C.) lJ oo-.0001 3/ 4 70
PLAN CHECKING FEE
Lender's Name 5110 1 AM11:50
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE f✓
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 Co ty to enter upon the above-mentioned property
for inspec' n purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
�SIGNAT E DATE