HomeMy Public PortalAbout9939 OLIVE ST_Electrical__ WORKER'S COMPENSATION DECLARATION { 76g8B3 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT lJ
I hel:eby affirm that I 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.3800 Lab.C.) rr
Policy No. � Company t'�'L• FOR APPLICANT TO FILL IN JOB
ADDRESS G ��
Certified copy is hereby furnished. New Residential Bldgs.&Pgplp NO. EACH FEE LOCALITY `�L/
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. 9:;10:5-o — $ ' $
NEAREST A t tC
dap rtmen �j Multi-family Sq.Ft. — CROSS ST. P'd,/
Date °t. Lw c�{ ����Applicant Residential Swimming Pools AS BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME
COMPENSATION INSURANCE
This section need not be completed If the work Involved b the First io MAIL ��� /L_
( P Y ADDRESS 8,
permit Is for one hundred dollars(5700)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY F1 W,0 .( Tel.No.3 p3L(S
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
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 G�
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS Jlkf
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)of Division 3 of the Business and CITYAk-
,?LJSX,. Cy T.I.No. 'Z
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSEJ7)1+io Class `L� a.•
Over 50 t0 100 InCI. REG.NUMB
ER ✓ d
1O Over 100 DISTRICT NO. R SSED BY Q
License Number _57 Lic.Class �"If� r V
` -� -s�!� ��}, `-- I r/ Services,Swbd.,MCC&Panelboards t_1'0/• G L• .c It
Contractor 1�IOU' C1'07`' Data �t�RIIG 0-399 Amp.Under 600 V DATE 0
6-A-1al
r_1 I am exempt under Sec. 400-1000 Amp.Under 600 V
VALIDATION U
Over 1000 Amp.or Over 600 V FINAL W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY co
te: ( ��cr 15A,or 20A,12OV,Lighting or Recept. Z
7 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Zinti
.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 2
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION ACCT.4
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3303 252°80
Code): 1 q ITEHS
F1 1, Conduits&Conductors
I,as owner of the property,will do the work.and the structure PC)
not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL ��
, 2 a
and Professions Code). CHECK 257°80
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the C r+HAE
°
00
performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) O
Civ.C.)
PLAN CHECKING FEE 0000-0001 4/18/96
Lender's Name PERMIT ISSUING FEE 5939 1 All'�1000°
o'� !)
Lender's Address p
I certify that I have read this application and under penalty of purjury state TOTAL FEE q�sj •d
that the 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 t nter upon the above-mentioned property
for ins rpo s. 4 SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURfOF PEI DATE