HomeMy Public PortalAbout10521 OLIVE ST_Electrical__ WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3!97 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self cE so6G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. 144y'110 Company16111 ve FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
n Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY `XL
' NEAREST
tion department. Multi-family Sq. Ft. CROSS ST.
Date i c Applicant. V!xx�f�Y';'�
Residential Swimming Pools OWNER OR
FIR M NAME L&V '*'
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL c
COMPENSATION INSURANCE Outlets: Rec Light Sw._ Gi,)?., S. s' MIZ,
ADDRESS
First 20
(This section need not be completed if the work involved by Total No. Additional CITY i Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—D.W. �� ♦ --
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS erri
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CITY PICC Tel. No.!06,;
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. — Room Air Cond. REG. NUMBER "1 !r Class. ,
I hereby affirm that I am licensed under provisions of Chapter 9 d
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY 0
and Professions Code,and my license is in full force and effect.
Size &Type HP, KW, KVA, or KVAR VV
License Number P}�y�Lic. Class G 1(4 Up to 1 Incl. FINAL J
Over 1 to 10 Incl. DATE VALIDATION U.
Contractor Date❑ Over 10 to 50 Incl. >_FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY Ir
Q
B.&P.C. for this reason LT Over 100 cc
Services, Swbd., MCC& Panelboards , O.,O
Dote: 0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— ,
Business and Professions Code). ( "`
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE z
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
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
(�)'
Signature of Permittee Date