HomeMy Public PortalAbout5821 MUSCATEL AVE_Electrical__ WORKER'S COMPENSATION DECLARATION20=0019 DPW(12-91)
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764663 APPLICATION FOR ELECTRICAL PERMIT J�
I hereby.affirm that I have a certificate.of consent to self insure, )
or a certificate of Worker's Compensation Insurance,or a certified I COUNTY OF LOS ANGELES DEPT.OF PUBL161WORKS BUILDING AND SAFETY DIV.
copy thereof(S 3 0 Laafb.C.) !
Policy N . I y FOR APPLICANT TO FILL IN j JOB /
ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. , EACH FEE LOCALITY / j
Certified copy is filed with the county building inspection I 1 &2-Family,Sq.Ft. _ $ $ NEAREST
depart ant. L� ,,// Multi-family wi Ft. CROSS ST.
Date 2 Applicant�G r�. fG/�. Residential Swimming Pools 1 MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. i OWNER OR
COMPENSATION INSURANCE FIRM NAME
M`S / j
First 20 MAIL [t ! /
(This section need.not be completed if the work Involved by the Total No. Additional ADDRESS /,3�M // ?Z�
permit is for'ons hundred dollars($100)or less.) /�� `
.l certify that in the performance of the work for which this permit CITY 6 A#A Tel.No. �I 7
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation.L"aw"s. Lighting Fixtures. First 20 ! APPLICANT
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 PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances. APPLICANT JVj /ed(O
LICENSED CONTRACTORS DECLARATION I Size&Type HP,KW,KVA,or KVAR ADDRESS o9.4 cl 4v4 K
I hereby affirm that I am 1'icensed'under provisions of Chapter 9 1 Over 3 to 10 Incl,
(commencing with Section 7000)of Division 3 of the Business and + CITY► AGA 4ze Tel-NalIVP— 777_
Professions Code,and my license is in full force and effect. i Over 10''to 50 Incl. }
LICENSE B IV Olass /y a
// J//
///,,,/// f Over 50 to 100 Incl. REG.NUMBER 2��� 7 �� V
1 S ^�J// Over 100' DISTRICT NO. O SSED BY 0
License Number J Lic.Class i r�J
Q r Services,Swbd.,MCC&Panelboards
Gf� j� �j��� �' +td �� f •I 0-399 Amp.Under 600 V
Contract
FINAL
DATE
F1 I'am exempt under Sec. I 400-1000 Amp.Under B00 V I (191-- V~ ' VALIDATION V
Over 1000 Amp.or Over 600 VIIIFINAL
BAP.C.for this reason BRANCH CIRCUIT FEES I BY
Date: 15A,or 20A,120V,Lighting or Recept. 1 Z_
1 To 10 Branch Circuits
Signature I 11 To 40 Branch Circuits
❑ Al Or More Branch Circuits
Exemption'for Reg.Maint.Elect. i 15A,20A,20BV To 277V Lighting Be.Circuits '
SINGLE FAMILY Temp.Power Pole&Appurtenances
NO FEE
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I.am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits j_:1;131 1i_f?(?t / )�
Code):
F11,as owner of the property,will do the work and the structure ' Misc.Conduits&Conductors 57
v 1 AM 10:yS-
!
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) I �R H.CtA*'
and Professions Code).. I '
CONSTRUCTION LENDING AGENCY
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)
Civ.C.)
PLAN CHECKING FEE'
Lender's Name I
PERMIT ISSUING FEE d.
Lender's Address g�
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 r
ordinances and State laws regulating Electrical wiring,and.hereby authorize
represents' es of this County to enter u n e above-mentioned property
for inspe o purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
87URE OF PER Le Orxr/x D � _
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