HomeMy Public PortalAbout10621 OLIVE ST_Electrical__ ON
TION 20-0019
I hereby affirm-WORKER'S ha have certtificlate of consent t tto self Insure, 76AS63 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
78A663
or d certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES 'DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy theraof..(Sec.3800 Lab,.C.)
P❑ollCy No. Company FOR APPLICANT TO FILL IN JOB �f.. V�y v
ADDRESS d
Certified copy li herebjfurnished. New Residential Bldgs.&Pools �(� NO. EACH 'FEE' LOCALITY e.
❑ 1 &2-Family,Sq.Ft.�� — $ $
Certified copy is filed with the county building inspection NEAREST v
department. Multi-family Sq.Ft. CROSS ST. L
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER CR
COMPENSATION INSURANCE FIRM NAME -& eve-Le rht
First 20 /
perms section need not be completed the work Inyolved'by,the Total No. Additional oDREss ��,
permit is for one hundred dollars(57000)or less.)
I certify that in the performance of the work for which this permit CITY 12,y—em, T.I.No. L-
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. Additional
� .�•1 ADDRESS
Date S Applicant�LU WIK l�l et RESIDENTIAL APPLIANCES NOT OVER.3 HP
NOTICE TO APPLICANT: If, after mak.irig this .Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP..
rovisions.of.the Labor Code,you must forthwith comply with such PERMIT
p L—W LrC pc t L
Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked. GEIS
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'. ��.
(commencing with-Section 7000)of'Divislon 3 of the Business and CITY �'Q�- Tei.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR Ty A?'3a 4 >-
CA"(
Over 50 to 100 Incl. REG.NUMBER [ ` J O class. d® a
License Number �7` 7 ® Lic.Class Over 100 DISTRICT NO.
PROCESS BY
�R' 0
Contractor, . r� LI fy RQ�ate 5 6 S Services,0-399 MCC&Panel 00 V DATE
0-399 Amp.Under 800 V FINAL ('
❑ Sec. 400-1000 Amp.Under 600 V w
O G VALIDATION
I am exempt under W
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY a-
Date: �.. 1.5A,or 20A,120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature 11 To 40 Branbh Circuits
❑ 41 Or More Brancli.Circuits
Exemption for Reg:Malin.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
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 Professions Additional Sign Branch Circuits
Code): ACCT=47
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors. ,y0Q0J=
94
is not intended or offered for sale.(Section 7044, Business Other(See Complete Fee Schedule) ' # rr�(
and Professions Code). I TOTAL 31:)3 6 94
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CHECK 30,75.94
performance of the work for which this permit is Issued(Sec.3097, PERMIT FEE (Sub-Total) ��§�a c01)
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 5/18/95
Lender's Address ,� 1 AM lj a
I certify that I have read this application and under penalty of purjury state TOTAL FEES;�.r
29
that the above information is correct. I agree to comply with all County
ordinances andtState aws. gulating Electrical wiring,and hereby authorize
representativeCo ty to enter upon the above-men•oned propertyfor ins ons. r SEE REVERSE FOR EXPLANATORY LANGUAGE
q5 .
sip"?
IQ RE OffPERMITTEE DATE