HomeMy Public PortalAbout9933 OLIVE ST_Electrical__ WORKER'S,COMPENSATION DECLARATION 76°O83 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT L1
I heregy of lIrm that I Nave a certificate of consent.to self insure,
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.)
C 'APPLICANT TO FILL IN 3 c
P 'FOR
❑Olicy No, ZZ�Ss& Company ADDRESS d
Certified copy is hereby furnished. New Residential Bldgs.&Pnb NO: $EACH 117— $ FEE LOCALITY � l�
1&2-Family,Sq.Ft.
❑ Cerfif'ied opy is filed with.the county building inspection _ �NEAREST
loss
de artm nt. / Multi-family Sq.Ft. ROSS, L/v`',')G Residential'Swimming Pool's Date Applicant PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw.
OWNER
RM NAME
COMPENSATION INSURANCE �� e �
First 20 MAIL
(This section need-not be completed If the work Involved by the Total No. Additional ADDRESS S (,h
permit is for one hundred dollars($.100)or less.) i
CITY Tel.No. -0:31,46I certify that'in.the performance of the work for which this permit 1�{I►b
is Issued, Ishall 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 "
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3.HP.
NOTICE TO APPLICANT: 14, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Wdrkers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code,you must forthwith comply with such PERMIT
Power Apparatus&Large Appliances APP
;provisions or this permit shall be deemed.revoked. LICANT lip �G
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KV.AR- ADDRESS q1 IJm�
I'hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. A
(commencing with Section 7000)of Division 3 of the Business and CITY /! Tel.No. �..��
Over 10 to 50 Incl. LICENSE OR
Professions Code,and my license is in full force and effect. ^1 '
Over 50 t0 100 Incl. REQ!NUMBER /7� a ClCl—C,j 0 O
Over 100 DISTRICT NO. P.RSED,BY V
License Number V Lic.ClassD
i /�� Services,Swbd.,MCC&Panelboards G
Contractor T- ey. lik-e Date 6 1/� 0-399 Amp.Under 800 V FINAL
❑ 400-1000 Amp.Under 600 V 1 2 VALIDATION W
f am exempt under Sec. Over 1000 Amp.Or Over 600 V FINAL a
B.&P.C.for this reason ` BRANCH CIRCUIT FEES BY j� Z 15A,or 20A,120V,Lighting or Recept. Z
Date: .
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 2
SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT e a
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �� �y[
I hereby affirm that I am exempt from the Contractor's License Law 3303 263.80
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 1 ITEMS
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 26 p„�0
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) CHECK 263.80
and Professions Code).
CONSTRUCTION LENDING AGENCY CHANGE "00
I hereby affirm that there is a construction lending agency for the J
performance of the work for which this permit is.issued'(Sec. 3097, PERMIT'FEE (Sub-Total) 6.1IJ
Civ.C.) 0000-0001 4/18/96
PLAN CHECKING FEE 5936 1 (aMID:0'{
Lender's Name
PERMIT ISSUING FEE O
Lender's Address penalty p TOTAL FEE 3 8�
oertify that I.have read this application and under P of. urj u.ry state . . ;
that the above information is orrect. I agree to comply with all County
crdinances'and State laws reg at Electrical wiring,and hereby authorize
representati of th Coun to enter upon the above- entio ed property
for Ins o urp s. la� 1SEE REVERSE FOR EXPLANATORY LANGUAGE
f LVA f/
SIGNATU OF P ITTEE DATE