HomeMy Public PortalAbout9935 OLIVE ST_Electrical__ N RKER'S COMPENSATION DECLARATION MIs DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 1'have 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.38000 Lab.C.) �l ,(rp `_
Policy No.122'75,a�ompany -6+` 1�1!� FOR APPLICANT TO FILL IN JOB Q
ADDRESS `35_
Certified copy is hereby furnished. New Residential Bldgs.&Po a NO. EACH FEE LOCALITY r
❑ Certified copy is filed with the countybuilding inspection 1&2-Family,Sq.Ft. y — $
d@part ent. 9 p MuId4amlly Sq.Ft. — NEAREST
/ p CROSS ST.
Date Z oTa. Applicant L-wL Wile- Residential Swimming Pools' ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light' SW. FIRM e
COMPENSATION INSURANCE
First 20 MAIL
(This section need not be 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 performance of the work for which this permit CITY Tel.No.3&D�tfS
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 APPLICANTK
Total No. 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 tleenied revoked.. I Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,,or KVAR ADDRESS qqC W tC04
I hereby affirm that I am licensed under provisions of Chapter.9 Over 3 to 10 Incl. �`' p
(commencing with Section 7000)of Division 3 of the Business and CITY �lJ�r� Tel.No. Ra
'Z
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
Over 50 to 100.Incl. LICENSE B IS)��3 O Clese;�
REG.NUMBER a
License Number S7nS 0. Lic.Class _to Over 100 DISTRICT NO. PROCESSED BY 0
- Services,Swbd.,MCC&Panelboards
Contractor/L we 1�yL�E(1c Date ` - 0-399 Amp.Under 600 VDA E
400-1000 Amp.Under 600 V
❑ I am exempt under Sec. _V"' ` VALIDATION V
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reason BY
L BRANCH CIRCUIT FEES U)
�+
Date: ` 15A,or-20A,12DV,_Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits 2
Exemption for Reg.Maint.Elect. i5A,20K 208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances AGCTeg t t+
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 3303 26,-80
1 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 1 ITEM
Code):
❑ * 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 263®80
is not intended or offered for sale(Section.7044,, Business. Other(See Complete Fee Schedule) , CHECK X63080
and Professions Code). �r r�r
CONSTRUCTION LENDING AGENCY CHANGE Q00
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.) '3 0000-0001 4118/95
Lender's Name PLAN CHECKING FEE 5937 1 AM10:07
PERMIT ISSUING FEE
Lender's Address TOTAL FEE
I certify that.I have read this ap ' ation and under penalty of purjury state
that the above information is rect. I agree to comply with all County
ordinances and State
we
reg Ing Electrical wiring,and hereby authorize I
repress ntativ of IN oun enter upon the above-mentions property
for in o urpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE i
SIGNATUF OF PE I DATE