HomeMy Public PortalAbout9561 LOWER AZUSA RD_Electrical__ WORKER S COMPENSATION DECLARATION 72�09 DPW(12 91) APPLICAT10 rFOR-ELECTRICAL PERMIT
1 hereby atfir that I have a certificate of Consent to self Insure
or aOcartificati-of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
P❑oicy N heS//A-796 Company �L civ FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished —/ New Residential Bldgs &Pools NO EACH FEE
t+ E LOCALITY
❑ Certified copy is filed with the county building Inspection 1&2 Family Sq Ft NEAREST
department Mufti family Sq Ft CROSS ST
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec -Light Sw OWNER OR V2!�,_
WNO _
COMPENSATION INSURANCERRM NA
(Thio section need not be completed the work involved by the First 20 MAIL
Total No Additional lj���
permit Is for one hundred dollars($1000)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
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICCANT
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 Power Apparatus&Large Appliances APPM_IT
provisions or this permit shall be deemed revoked _
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS,/Q? 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 To No
Professions Code and my license is in full force and effect Over 10 to 50 Incl
LICENSE ORChase lO IZ
Over 50 t0 100 Incl REO NUMBER/'76
Over 100 DISTRICT NO PRKESSED BY O
License Number Lic Class U
Services Swbd MCCJ&Panelboards
Contractor Date 0; p V 540 DATE
9_NA
E] 400 1000 Amp Under 600V U
I am exempt under SecVALIDAT
Over 1000 Amp or Over 60ION W0 V FlNAL d
B&P C for this reason BRANCH CIRCUIT FEES BY ct)
Date 15A or 20A 120V Lighting or Recept ?
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ Exemption for Reg Maint Elect 15A,20A 2208V To 2M t More Bir Gra is MW ITEMS Tis
SINGLE FAMILY Temp Power Pole&Appurtenances Gh7
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 65
I hereby affirm that I am exempt from the Contractors License Lew e
for the following reason(Section 7031 5 Business and Professions Additional Sign Branch Circuits
Code)
❑ 1 as owner of the property will do the work and the structure Mtsc Conduits&Conductors 01ECK 65.60
is not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule) , 0000-=1 8/16/95
and Professions Code)
CONSTRUCTION LENDING AGENCY i 1n
I hereby affirm that there is a construction lending agency for the 1881 1 AN10=41
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub-Total)
Civ C)
PLAN CHECKING FEE
Lender a Name
PERMIT ISSUING FEE
Lender a 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 enter upon the above-mentioned property
for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMIT EE DATE