HomeMy Public PortalAbout10158 OLIVE ST_Electrical__ WGTKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT.
I here+d�y.gffirm �ia'tl'have a certificate of consent to self insure, 76A683 f
,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 Lab.C.) _
Policy No. Company FOR APPLICANT TO FILL IN JOB yn a
ADDRESS D 1 O
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
1 &2-Family,.Sq.FL — $ $
e4 Z
❑ Certified"copy is filed with the county building Inspection — NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
PAGE �� PARCEL®�
CERTIFICATE OF EXEMPTION FROM WORKERS' fl �] OWNER OR f �.
COMPENSATION INSURANCE ' outlets:Rec._Light Sw.'_7— /�v l FIRM NAME
First 20 (p MAIL
(This section need not be completed if the work Involved by the Total No. Q Additional 6� ADDRESS 44.1 7
permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY le j 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 / APPLICANTTotal No.—/,Q! 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 APPLICANT
IT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances ti� u>
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW V KVAR DDRESS
I hereby affirm that I am licensed under provisions.of Chapter 9 � er0 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 }
Over 50 to 100 Incl. REG.NUMBER Class O
License Number Lic.Class Over 100 DISTRICT NO. RR SED BY V
Services,Swbd.,MCC&Panelboards
Contractor- Date 0-399 Amp.Under 600 V DATE i U
❑ I am exempt under Sec. 400-7000 Amp.Under 600 V FINAL t ��Z� J U3
VALIDATION
Over 1000 Amp.or Over 600 V /� _ / IL
B.&P.C.for this reason BY (/,� x Z
BRANCH CIRCUIT FEES e� �f
Date: 15A,or 20A,120V,Lighting or Recept. —
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits
❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILYr�
Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 0
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 �`rr2
Code)• MOM
❑ I,as owner of theproperty,will do the work and the structure Misc.Conduits&Conductors s,h;
'1 Il t i'IL..
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t
and Professions Code). I
CONSTRUCTION LENDING AGENCY ,,
r
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)
Civ..C.) / '+t'-
PLAN CHECKING FEE
Lender's Name Pill'
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE !p d
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, a ^ / �� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIONATURflOF PERMITTEE DATE