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HomeMy Public PortalAbout5013 PAL MAL AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 76A663 DPW(12-91) r APPLICATION FOR ELECTRICAL PERMIT Iltereby 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.3800 Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ ADDRESS SO /� Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE `F Cr r Q/ ❑ = $ yf f / Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ LOCALITY 7,e department. Multi-family Sq.Ft. CROSS ST. Ke fq/(- S 71 Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Light aO )Z Sw. OWNER OR13 COMPENSATION INSURANCE Outlets:Rec._ r s� FIRM NAME ► C9 99e � First 20 / �� ®� MAIL (This section need not be completed If the work Involved by the Total No. Additional.9 t ADDRESS permit is for one hundred dollars(6100)or less.) I certify that in the performance of the work for which this permit CITY �fa T.I.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting FixturesFirst 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. M provisions of the Labor Code, you must forthwith comply with such Power Apparatus&Large Appliances AIT PPPERLICANT provisions or this permit shall be deemed revoked. �© r �� �� LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 6-3 Over 3 to 10 Incl. 4 (commencing with Section 7000)of Division 3 of the Business and CITY Tt. r � Zoe T.I.N.. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR >_ Over 50 to 100 Incl. REG.NUMBER Class. 0_ Over 100 DISTRICT NO. PR C SED BY O License Number Lic.Class Services,5 :,MCC&Panelboards O �y� cc Contractor Date . F> aa-3J99 Amp.Under 600 V C DATE O ❑ 400-1000 Amp.Under 600 V V I am exempt under Sec. VALIDATION UJ Over 1000 Amp.or Over 600 V FINAL , `r• 0. 8.&P.C.for this reason CP »'►F O t.V k P s` BRANCH CIRCUIT FEES BY Date: 15A,or 20A,120V,Lighting or Recept. d _ 1 To 10 Branch Circuits q Signature Q 11 To 40 Branch Circuits F141 Or More Branch Circuits I yr Exemption for Reg.Maint.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): S-1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). CONSTRUCTION LENDING AGENCY 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.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and under penalty of puqury state TOTAL FEE 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 to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE aa '/'? Qa SIG URE OF PERMITTEE DATE