HomeMy Public PortalAbout4700 H MILLER DR_Electrical__ :WORKERS'COMPENSATION DECLARATION 26A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT
J.hereby'affirm thbt I have'a certificate of consent to self CES e G
P
4nsure;or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a�cert'fiAd copy thereof(Sec. 3800, La C.)
Policy�.-�Compan FOR APPLICANT TO_FILL IN JOB1-17' 40
+/
❑Certified copy is hereby furnished. /- 2 EACH NO. FEE ADDRESS, ' Q 0 �,(9 ed� i
/—� New Residential Bldgs. &Pools
❑Certified copy is filed with the countIf
y building inspec- 1 &2-Family,Sq. Ft. $_ — $. LOCALITY'Ze . . .ifl e (J/i1/
tion department ���;r �� Multi-family Sq. Ft. NEARECEASES T. l,.L
Date Applicana 7 �(� • i Residential Swimming Pools OWNER OR
[[(( FIRM NAME 6L9O) y
_
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light iiLKSw./7
COMPENSATION INSURANCE MAADDIL RESS • 3A
First 20 A1,r V
(This section need not be completed if the work involved by. Total No. Additional CITY�Yr� Tel. N
the permit is for one hundred dollars.($100)or less.).
PLA
I certify that in the performance of the work for which this p A PLICANTK
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20' Q
Date �d ADDRESS
so as to become-subject to the Workers'Compensation Laws.
' Additional
Total.No. 1-6 CITY Tel. No.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of L. Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION �.. A ' Q t✓,
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS i
with comply with such provisions or this permit shall be Top — FAU W.H. � r
deemed revoked. CITY Tel. Not ���
LICENSED CONTRACTORS DECLARATION Hood — Fan Other— ���^^ ,pp,1�1� +✓
Disp. _ Room Air Cond. �J vV LICENSE M 77W� /9'A9
I hereby.affirm that i am licensed under provisions of Chapter 9 REG.NUMBER Class(,
(commencing with Section 7000)of Division 3 of the Business , Power Apparatus&Large Appliances DISTRICT NO. P SED FiY >-
and Professions Code,and my license is in full force and effect. Type
d' O ��
� Size&T e HP, KW; KVA, or KVAR A /i � 0�
License Num er Lic. Class ry �yUp to 1 Incl. FINAL V
Contract is AK ow.e� Date '-7 ' 14� Over 1 to 10 Incl. � DATE 11
y1/i_ql L VALIDATION 0
❑ Over 10 to 50 Incl. Y l
FINAL U
1 am exempt under Sec. Over 50 to 100 Inc. BY
W
B.&P.C.for this reason Over 100
Cl)'
Date: Services, Swbd.., MCC&Panelboards. /p�B,p � Z
0-200 Amp. Under 600'V O —
Signature 201 - 1000 Amp. Under 600 V
❑ Amp. or Over 600 V Exemption.for Reg. MaintOver 1000. Elect. '
SINGLE FAMILY Temp. Power Pole&Appurtenances �-
HOME OWNER-BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Sign with One Branch Circuit t+i;C I.:F
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits _ _
Professions Code): `
❑
nd the Misc. Conduits&Conductors �,TE1
I, as owner of the Property, will do the work a
Other.(See Complete Fee Schedule)—
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). 1& 16 ��® 90
CONSTRUCTION LENDING AGENCY ` CHECK
I hereby affirm that there-is a construction lend1ng agency for CHANGE the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) �` d
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name ljl l ltl— )il i F
PERMIT ISSUING FEE . V 4
Lender's Address TOTAL FEE 6 AN T.,ti 9
1 certify that I have read this application and state that the 8
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 '
e abov ntioned propeqWfor inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
J",-/07-
Signature of Per ittee Date ®�