HomeMy Public PortalAbout5734 NOEL DR_Electrical__ WORKER S COMPENSATION DECLARATION MM19 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT Ll
I�iereby affirm thSt I have a certificate of consent to self insure
or%certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO RLL IN JOB
ADDRESS G
Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE
1-3LOCALITY
_ $
Certified copy is filed with the county building &2 Family Sq Ft gJ $
lding inspection NEAREST
department Multifamily Sq Ft CROSS BT L Q
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK 10PASE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS OWNER OR
COMPENSATION INSURANCE Outlets ReLight SW 480 2 FIRM NAMETaq
(This section need not be completed If the work Involved by the First J MAIL
permit Is for one hundred dollars(5100)or less) Total No Additional ADDRESS y� .S
I certify that in the performance of the work for which this permit &46 Tel 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
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances
ANT
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS
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 Tel No
Professions Code and my license is in full force and effect Over 10 to 50 Incl
LICENSE Claes d
Over 60 t0 100 Incl REO NUMBER
License Number 611 ��� Lic Class Over 100 DISTRICT NO PROCESSED S 07
Services Swbd MCC&Panelboards D
Contractor de '+ Date 0 399 Amp Under 600 V3:7 0
❑ 400 1000 Amp Under 600 V � VALIDATION
DATE
1 am exempt under Sec Over 1000 Amp or Over 600 V FINAL W
B&P C for this reasonBRANCH CIRCUIT FEES By 2
�
Date 15A or 120V Lighting or Recept AC * Z
Signature 1 To 10 Branch Circuits
11 To 40 Branch Circuits 0-❑ cc 41 Or More Branch Circuits
Exemption for R Maint Elect 15A 20A 206V To 277V Lighting Br Circuits 1 ITEMS
FAMILYSINGLE Temp Power Pole&Appurtenances
HOME OWNER BUILDERDECLARATION PTAL 206 m 5'5
1 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 CHECK 206 9"
Code) CHANGE .00
❑ 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)
and Professions Code) 0000-0001 9/23/91t
CONSTRUCTION LENDING AGENCY 7068 1 PM 4.49
1 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
PERMIT ISSUING FEE
Lender s Address
1 certify that I have read this application and under penalty of purlury state TOTAL FEE �v(ij P
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 inspsetio rpose Q SEE REVERSE FOR EXPLANATORY LANGUAGE
1
SIGNATUBW PERMITTEE DATE I