HomeMy Public PortalAbout6610 OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 76A663 DPW (12 91)' APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self Insure,
or a 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 Cab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB 1
ADDRESS '+ +�
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE �LOCALITY
❑ $ $Ft
Sq. . _
Certified copy is filed with the county building inspection 1 &2-Family, NEAREST .�� O
department. Multi-family Sq.Ft. CROSS ST. fi (r+r
Date Applicant Residential Swimming Pools ASSMAPBOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' 9 J_;-2- � OWNER ME '�`
Outlets:Rec. LightSw. s� t 6{' FIRL9 NAME
COMPENSATION INSURANCE V+•
First 20
(This section need not be completed If the work invofvod by the Total No. Additional rel f ADDRESS
permit is for one hundrod dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY Tel.N
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. ta• Additional ' ay, 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 APPLICANT
Power Apparatus&Large Appliances
provisions or this permit shall be deemed revoked.
.7!
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. CITY Tel.No.
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR d
Over 50 to 100 Incl. REG.NUMBER Class'
Over 100 DISTRICT NO. EBBED BY V
License Number Lic.Class
Services,Swbd. `�g P elb. r r/ �r 4"."1 _, Lam` It
Contractor Date3Jp.Und r 600 Io �� DATE U
r_1400-1000 Amp.Under 600 V VALIDATION UJ
I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL
B
B.&P.C.for this reason BRANCH CIRCUIT FEES
Date: 15A,or 20A,120V,Lighting or Recept. —
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits 1
F141 Or More Branch Circuits ti
Exemption for Reg.Maint.Elect. 15A,20A,20 VV To 277V Lighting Br.Circuits I ACCT.a
SINGLE FAMILY Temp.Power Pole&Appurtenances 3303 150.GG
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law 1 ITENS
EMS
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
code: TOTAL ]1 a0 o 113`01I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors CHECK 15G.CC
Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
CHANGE n 31
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the CMD-00191 3f 4/96
performance of the work for which this permit Is issued(Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.) 5177 1 AN11:13
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
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
representatives of this County to enter upon the above-mentioned property
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
N OF PERM EE DAT