HomeMy Public PortalAbout9913 LOWER AZUSA RD_Electrical__ WORKER'S COMPENSATION DECLARATION 20 M DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
78A663
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES [WPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C) 4
❑
Policy NO Company FOR APPLICANT TO FILL IN JOB J'
NO EACH FEE ADDRESS ad `7
Certified copy is hereby furnished New Residential Bldgs &Pools LOCALITY
❑ Certified copy is filed with the county budding Inspection 1&2-Family,Sq Ft — $ $
NEAREST
department Multifamily Sq Ft CROSS ST
Date Applicant Residential Swimming Pools ASSESSOR
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec _Light Sw OWNER
FIRMCOMPENSATION INSURANCE FIRM NAMMEE
First 20 MAll
(This section need not be completed if the work Involved by the Total No Additional ADDRESS
pdrinit is for one hundred dollars($100)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 s to PLAN C ECK
become subject to the Workers'Compensation Laws Lighting Fixtures First 20 APPLICANT
Total No Additional ADDRESS
Date Applicant klDtNTIAL
APPLIANCES NOT OVER 3 HP
NOTI APPLICANT If, after making is Certificate of CITY Tel No
Exemption,you should becomesubject to the Wo rs'Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code, you must forthwit omply with such PERMIT
power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoke
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 3 0
hereby affirm that 1 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 �1 /
Over 50 to 100 Incl REO NUMBER pC Cl. d
q?VOver 100 DISTRICT NO PROCESSED BY O
License Number L1'c Class ()
Services,Swbd,MCC�By,P�i d �i �� cc
T �� (v FINAL
0- 9A p n er O
Contractor Date J� 6 DATE
❑ 40 1 Amp nder _ H
I am exempt under Sec VALIDATION V
Over 1000 Amp or Over 600 V FINAL I III
B&P C for this reason BRANCH CIRCUIT FEES BY co
lade 15A,or 20A,12OV,Lighting or Recept Z
1 To 10 Branch Circuits
Slgnat�re 11 To 40 Branch Circuits
❑ Exemption for Reg M Elect 15A,20A,208V To 277V OrA;Branch G ui�da CCT a e
SINGLE FAMILY Temp Power Pole&Appurtenances 3M7 7`e-f
e 65
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit i IT
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits
Code) TOTAL •
y
❑ 1,as owner of the property,will do the work and the structure Mlsc Conduits&Conductors CE(# 97,65
is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) I
and Professions Code)
00M 000–
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the 1 3/22/935performance of the work for which this permit is issued(Sec 3097, PERMIT FEE (Sub-Total) �Vut�
Civ C) W 11 1 F"12:10
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE p�
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE -;7. (p
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
S!"TURE OF PERMITTEE DATE