HomeMy Public PortalAbout6217 MUSCATEL AVE_Electrical__ WORKER'
DECLA
ON 20-0019
ON
I.hereby affi'r'm thgt I ha eMa certificate iof conse t to self insure, 76A663 DPVJ'(12-91) APPLICATION FOR ELECTRICAL PERMIT
or:a certificate of'Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy theredf(Sec.3800 Lab.C.)
Poll .NO• ( zo�AC :Company �' "`C IUD FOR APPLICANT TO FILL IN JOB //J�
ADDRESS 62 /��:U C
Certified co Is harsh furnished: NO. EACH FEE LOCALITY C
copy� y New Residential Bldgs:&Pools
= '$i.. f - - .
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST
departmen Multi-family Sq.Ft. CROSS ST. 1 &4 �!1 /�
Date ?8 ^' Applicant
Residential Swimming Pools MAP BOOK � g.fo PAGEvv. PARCEL��
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FFIIRM NAME
COMPENSATION INSURANCE
This section need not be completed If the work Involved b the First MAIL.
( p y Total No. Additional -N, ADDRESS -
permit is for one hundred dollars($100)or lase.)
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. 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 ��
p P y Power Apparatus&.Large Appliances APPLICANT
provisions or this permit shall be deemed revoked. _
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS tfttErG` f`
I hereby affirm that I am. licensed under provisions bf Chapter 9 • Over 3.to 10 Incl.
(commencing with Section 7000)of Division 3 of the Business and. CIN M L�. ff`7 Tel.No. 2,K-067
Professions Code,and.my license is in full force and effect. Over 10 to 50 Incl.
LICENSEOR Cite }
• Over 50-to 1001hc1.. REG,.NUMBER_ J •a
IC_
License Number Lic.Class ty Over 100 DISTRICT NO. PRWSED BY O
(�
y Services,SWbd.;MCC&Panelboards J'a
Contractor Date a 0-399 Amp.Under 600 V DATE 0
0 I am exempt-under Sec. 400-1000.Amp.Under 600 V 41-Z44A VALIDATION W
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.-for this reason BRANCH CIRCUIT FEES BY W
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 2
Exemption for Reg.Maint Elect. 15A,20A;.208V To 277V Lighting Br.Circuits �/++r
SINGLE FAMILY Temp.Power Pole&Appurtenances A4FrTeF
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �3369.29
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 1 ITEMS
Code): -
Misc.Conduits&Conductors TOTAL 369 .29
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) , CHECK 369-29
and Professions Code),
HAEE e00
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) OJ ry� 0000-0001 5/28/96
Civ.C.) PLAN CHECKING FEE 6593 1 AM E:15
.Lender's Name
PERMIT ISSUING FEE C2 Q
Lender's Address TOTAL FEE ✓ ,
I certify that I have read this application and under.penaity of purjury state
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 In a Ifor ins ion pu SEE REVERSE FOR EXPLANATORY LANGUAGE
- - -L "P -
SIGNATURE OF PERMITTEE DATE -- -