HomeMy Public PortalAbout6034 OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION278 9 PW 9,89 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, f. h I
or a certificate of Worker's Compensation.Insurance,or a certified C UNTY OF LOS ANGELES'S DEPT.OF PUBLIC.WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec:3800 Lab.C.) i
P❑ollcy No. Company I FOR APPLICANT TO FILL IN ADDRESS fo�3y
Certified ca is hereb furnished. 9 $EACH NO. $ FEE LOCALITY
PY Y Now"Residential Bldgs.&Pools
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. CROSS ST. LX 44=
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK I PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outl Outlets:Rec._Light Sw. FIRM R OR �-] �
COMPENSATION INSURANCE ,
(This section need not be completed If the work Involved by the First 20 MAIL `r
permit Is for one hundred dollare($100)or:less.)
Total No. Additional I ADDRESS
I certify that In the performance of the work for which this permit I _ CITY r�.�P�� Tel.No.2� '•270
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Work ompensa io Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
-19/719—Ar Z I
Date Ap nt• 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making t .Ie Cerfifl tato of CITY Tel.No.
Exemption,you should become vubject to the Workers,Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
provisions or this permit shell be deemed revoked. 4U OR MORE BRANCH CIRCUITS EACH APPLICANT
LICENSED CONTRACTORS DECLARATION 15..'OR 20A,206V TO M LIGHTING EACH ADDRESS P0 G0 V' IIZRC:l CL
I hereby affirm that I am licensed under provisions of-Chapter 9 �. C
(commencing with Section 7000)of Division 3 of the Business and CITY •I%&-t-4PL-E CITY Tel.
Professions Code,and my license Is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR IX
Power Apparatus&Large Appliances REG.NUMBER �Qo327� ��e GO
i C
License Number O�Z7 Lic,Class. G
Up to 3 Incl:Bile&Type HP,KW,KVA,or KVAR DISTRICT NO. p PRCED BY
6�B a LL
�
Over 3 to 10 Incl. FINAL t1U
Contractor Date Over 10 td 50 Incl. DATE
❑ I am exempt under Sec. Over 50 to 100 Incl. VALIDATION
• - FINAL -
B.&P.C.for this reason Over 100 BY l
Services,Swbd. EVII
elboards
Date: 0-200 V
y Signature 20,1-1000 Amp0 V-
❑ Exemption for Reg..Maim.Elect. Over 1000 Amp,or Over BOU V ACCTAJL
SINGLEFAMILY Temp.,Power Pale&Appurtenances 07 59.55
HOME OWNER=BUILDER DECLARATION Sign with One Branch Circuit 1 ITEMS I hereby affirm that I am exempt from the Contractor's License Law ,GGA�,7
for the following reason(Section 7031:5, Business and Professions Additional,Sign_Branch Circuits
Code): ; TOTAL 59'.55
❑ I,as owner of.the property,will do the work and the structure Misc.Conduits&Conductors - CHECK 59.55
Is not Intended or offered for sale(Section 7.044, Business Other(See Complete Fee Schedule)
and Professions.Code). , CHANGE ■OO
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency for thetry� i $r ,
performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) { 0WRJJ
92
Civ.c.) f l 5195 1 AM1023
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address i
(:.certify that I have read,this application and.state that the above TOTAL FEE �� J
information is correct. I agree to comply with all County ordinances
and.State laws regulating Electrical.wiring, and hereby authorize
r thisou o r upon.the:above-mentioned t
property f r Ins e p rp SEE REVERSE FOR EXPLANATORY LANGUAGE
;
SIGNATURE OF APP -DATE y