HomeMy Public PortalAbout10539 OLIVE ST_Electrical__ ON
I hereby affirm-tRhal-I have Ma cerrttificlate of DECLARATION
o sentOto self Insure, �►g3 DPW(12 91) APPLICATION FOR. ELECTRICAL PERMIT
or a ce[tifkate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
cdpy thereof(Sec.3800 Lgb'C.) •
Policy No., •i Company FOR APPLICANT TO FILL IN JOB ��
ADDRESS (1 �/�J 7
❑ CertMed co Is hereby furnished. NO. EACH FEE LOCALITY
PY Y New Residential Bldgs.&Pools
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ $ $
NEAREST
department.. Multi-family Sq:Ft. opOSS ST.
Residential Swimming Pools
Date Applicant ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw.�� s ' 3 r o "NAME
' COMPENSATION INSURANCE First 20
(This section need not be completed If the work Involved by the MAIL Z
permit is for one hundred dollars($100)or less.). Total No. Additional Q ADDRESS
I certify that in the performance of the work for which this permit CITY �� Tel.No. z Z
is Issued, I shall,not employ any person in any manner so as to PLAN
'become subject to the Workers'Compensation.Laws. Lighting Fixtures First 20 APPL CHECK
J9 4O APPLICANT
Total No. Ly 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 PERMIT
provisions or this permit'shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED.CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR AD R SS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. gA Wolf
(commencing with Section 7000)of Division 3 of the Business and CITY rel.No.
Professions Code,and my license Is in full force and effect. Over Over 50 50 to 50 Incl.
to 100 Incl. LICENSEOlase
REG.NUMBER
�
License Number Lic.Class Over 100 DISTRICT NO. P.5QCES.SED BY V
Services,Sw5d.,MCC&Panelboards
Contractor Date 0-399 Amp.Under 800 V , Q� 7 DATE
❑' 400-1000 Amp.Under 800 V "Qj VALIDATION V
I am exempt under Sec. Ovet 1000 Amp.or Over 800 V FINAL W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY co
Date: 15A,or 20A,120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits i�•• ".
F141 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances f 3
HOME OWNER-BUILDER DECLARATION it
h Circuit
rcu
with One r +''" m
I hereby affirm that I am exempt from the Contractor's License Law Sign Ar"11.(,�
for the following reason(Section'7031.5, Business and Professions Additional Sign Branch Circuits Oy
Code• {tJiJ i L!s IQ!
rl,as owner of thero ert MiscConduits&Conductors,will do the work and the structure .
P P Y 1 NEM
is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) r=
and Professions Code). ,®/ i E Iii1- {-' m "
CONSTRUCTION LENDING AGENCY 11MCK '
I hereby affirm that there is a construction lending agency for the MANGE
performance of the work for which this permit is issued Sec.3097, ("
P P ( PERMIT FEE (Sub-Tota
Civ.C.) l��st
PLAN CHECKING FEE
Lender's Name ill;l+ l�I ILS E 7/14/91t
PERMIT ISSUING FEE r,� , To 51
Lender's Address t3)
1•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 45
ordinances a StJhIto
iating Electrical wiring,and hereby authorize
represent sof enter///++++++pon the above-m ntioned.p party
for ins n purSEE REVERSE FOR EXPLANATORY LANGUAGE
81QN?kTURFq PERM TI DAT