HomeMy Public PortalAbout5827 MUSCATEL AVE_Electrical__ WORKEja'S COMPENSATION,DECLARATION 20-0019 DPW(12.81) APPLICATION FOR ELECTRICAL PERMIT .
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I hereby affirm that) have a certificate of consent to self insure, 78A663
or a r�ertMiate sof worker's Compensation, surance, or a certified _COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy ther Of(Sec.3800 Laab..��:)
PO ICy NO. l+Orf7ny ��- FOR APPLICANT TO FILL IN JOB
ADDRESS �� t (j•�rG}�t\�•
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
1 &2-Family,Sq.Ft. 'Z�7 _ �
Certified copy is filed with the coup building Inspection NEAREST
department. Multi-family Sq.R. CROSS ST. J�1
�—�� v� Residential Swimming Pools ASSESSOR n
Date Applicant �{/
MAP BOOK �P � PAGE PARCEL C//
CERTIFICATE OF EXEMPTIO ROM WORKERS' Outlets:Rec._Light Sw. OWNER
IPM NAME (J NAJ
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by the First s , !
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS
MAIL
I certify that in the performance of the work for which this permit CITY ho-61,0D S Tel.No.�
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. 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 rel.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 APPLICANT «� l� �� LL
IT
provisions or this permit shall'Us deemed revoked: Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS �Z �'�� ,Gw�e>ey
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 �� i Tel.No. cfcos'
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.. r2 ff
Over 50,to 100 Incl. LICENSE OR !ss Class. (ID C"
CL
License Number (f Lic.Class Over 100 DISTRICT NO. G P� SE-�D BY V
$� t� "4
Services,Swbd.,MCC&Panelboards BGG a-� 1=Contractor`` '�Y� V"'�"'� -Date � 0-399 Amp.Under 600 V DATE 0
❑I•am exempt under Sec. 400-1000 Amp.Under 600 V 6
v/ VALIDATION V
Over 1000 Amp.or Over 600 VW
B.&P.C.for this reason BRANCH CIRCUIT FEES co
BY AL d
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits ,
❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 330_6 0_6 2.3 L
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION = r}=
ith Cir
Bra
with One Branch cu
I hereby affirm that I am exempt from the Contractor's License Law Sign w .+—,r,--°
79
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits :IN
-+—� "m
Code): r —"
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) °LI`I
and Professions Code).
CONSTRUCTION LENDING AGENCY :{ as tr;
I hereby affirm that there is a construction lending agency for the ;"Il��► I -j71jJ1 j' f+ z
performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) 4279 1 Pri 6:011
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE !O
Lender's 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 t
representatives of this County to enter upon the above-mentioned property
for inspect purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
� ,meq C'
SIGNATURE O ERMITTEE DATE