HomeMy Public PortalAbout6211 MUSCATEL AVE_Electrical__ ° WQRKER'S COMPENSATION DECLARATION 20-0019 DPW(12=91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm thaf I have a.certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES 4 DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.) ll1T T�. `•
�y No. 2 �� Company v '•� r`^ FOR APPLICANT TO FILL JOB
Certified copy is hereby furnished. New Residential Bldgs.&Pooh NO. EACH F E LOCALITY
y,Sq.Ft. — $ SIC Cf
1 &2-Famil
❑ Certified copy is filed with the county building inspection — �� NEAREST
department. Multi-family Sq.Ft. �7 =/ CROSS ST: CA
Residential Swimming Pools ASSBOEOR •��•/ P � PARCEL'S
Date Applicant I MAP BOOK vt7 W
CERTIFICATE OF EXEMPTION FROM WORKERS' ;
OutletRec.—Light Sw. OWNER OR
Outlets:COMPENSATION INSURANCE FIRM NAME
First 20 MAIL
(This section need not be completed If the work involved by the Total No. Additional ADDRESS.
permit 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.as to PLAN CHECK
become subject to the Workers'Compensation Laws. II 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 i CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation ',,OTHER APPLIANCES'NOT OVER 3 HP.
rovisions of the Labor Code,you must forthwith comply With such PERMIT �.�C
P Y P Y APPLICANT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION ( Size&Type.HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 1 Over 3 to 10 Ind. -
(commencing with Section 7000)of Division 3'of the Business and CINC� Tel.No.
Professions Code,and:m license is in full force and effect. Over 10 to 50 Incl.
Y i' LICENSE OR. Class: a
Over 50 to 100 Ind. 'REG.NUMBER Q �.
C, C� Over 100 DISTRICT NO. EBBED BY V
License Number 0 )�r Lid.Class
Services,Swbd.,MCC&Panelboards
0-399 Amp.Under 600 V FINAL O
Contractor Date DATE V
❑ !. 400-.1000 Amp.Under 600 V v VALIDATION LU
I am exempt under Sec. _ Over 1000 Amp.or Over V FINAL p,
BAP.C.for this reason BRANCH CIRCUIT FEES BY a� co
Date:
15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El41.Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits `
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sigh with One Branch Circuit ACCT.01
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 3303 369.29
Code): 1 ITEMS
❑ Misc.Conduits&Conductors S
I,as owner of the property,will do the work and the structure
is not intended or offered for sale(Section 7044, Business. Other(See Complete Fee Schedule) TOTAL :369-29
,
and Professions Code). CHECK 369.29
CONSTRUCTION LENDING AGENCY CHANGE .00
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) JAII
Civ.C.)
PLAN CHECKING FEE 0000'000.1 5/28/96
Lender's Name
PERMIT ISSUING FEEtpf- ()' 692 1 AM 8:14
Lender's Add
I certify that I have read this application and under penalty of purjury state TOTAL FEE ,p� /
i
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
_ �7a9-
SIGNATURE OF PERMITTEEOF PERMITTEE
DATE