HomeMy Public PortalAbout10209 OLIVE ST_Electrical__ VORKER'S-COMPENSATION DECLARATION X139 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 11
t Ke'reby fllflrrkthat f have a certificate of consent to self Insure,
dr'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..3600 Lab.C.)• ,
Policy No. Company FOR APPLICANT-TO FILLIN JB e� 1 �.r®
❑ !A-D5DRESS a(, y t�C.
Certified copy is hereby fuiriished. New Residential Bldgs.&Pools NO. EACH FEE CALITY
Certified copy is filed-with the county building inspection 1&2-Family,Sq.Ft.Z .D.0 $t $ NEAREST
department. Multi-family Sq.Ft. CROSS ST. �r ,J
Date Applicant. Residential Swimming Pools ASSESSOR QL�,� PAG PARCEL.046
- MAP BOOK U pdI
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR
COMPENSATION INSURANCE• Outlets:-Rea._Light Sw. FIRM NAME
(This section need not beFirst 20 MAIL
'completed if_the work Involved by the Total No. Additional ADDRESS
permit is for one hundred'dollars($100)or less.)
I certify that in the perfbrmance of the work for which this.permit CITYfA AA-C Tel.No.
is issued, I shall not employ ariy person in any manner so as to PLAN CHECK,
become subject to the.Workers.%Compensat(on Laws. Lighting Fixtures First 20 APPLICANT
r!p a Total No. Additional
e�,Ia7.l '[.�, 1,. V �1�G•1'/`r,(,' ADDRESS
Date Applicant d...CI�9t� �r RESIDENTIAL'APPLIANCES NOT OVER,3 HP.
NOTICE TO APPLICANT: If, .after making' this Certificate of CITY' Tel.No.
Exemption,.you shouldbecome subject to the Wbrkers•'Compensation OTHER APPLIANCES NOT OVER'3 HP. .
provisions of the Labor Code,,you must forthwith comply with such PERMIT 1 ,, -- aa •
provisions or this permit shall.be deemed revoked. Power Apparatus&Large Appliances APPLICANL
T w L W ��-•.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS �V�' •�
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 anti . CITY ,A� ILS Tel.No.TgS,�
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
5�7p q- :G.�.
Over 50 to 1.00 Incl. LICENSE OR Class
, REG.NUMBER• lY a7� a
�� 5 C'_a Over 700 bISTRICT NO. P o SSED BY V
License Number lie.Class
® Services',Swbd.,MCC&Panelboards
ContractorLLVr 6 i Lrc mienL 4 Date vn�� 0-399 Amp.Under 600 V FINAL
❑ •- •, DATE / I"
I am exempt under Sec. 400-1000 Amp.Under 600 V ^3•lfy�
VALIDATION V
Over 1000 Amp.or Over 600 V.
" FINAL
YAL a
-B.&P.C.forthis.reason' BRANCH CIRCUIT FEES
Date: • 1bA,or 20A,120V,:Lighting or Recept. i Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El
41 Or More Branch Circults
Exemption for Reg.�Mamt.Elect." .15A,20A,208V Td 277V Lighting Br...Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances b
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit i`
I hereby iiffirm'that I am exempt from the Contractor's License Law (� •L j='as
for the following reason (Section 7031.5, Business.and Professions, Additional Sign Branch Circuits �� , 9 (•� �
Code): L.r,ar93 tt rt3 a s
❑ 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)
�, A �'c
and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK 130.85
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.)
PLAN CHECKING FEE
2/27
Lender's Name PERMIT ISSUING FEE -) l I ^M •95
TOTAL FEE
Lender's Address / 1 p
I-certify that I have read this application and under penalty of purjury state ✓ �.��
that the above information is correct. I agree to comply with all County
ordinance's and State laws regulating Electrical wiring,and hereby authorize
representatives of this County to enter upon the above-mentioned property_
for Inspect' I pir uses: SEE'REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE JFPERMITTEE DATE