HomeMy Public PortalAbout5503 PARMERTON AVE_Electrical__ WORKER I haveCOMPENSATION of consent to }r 76ABBe DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT IJ
00019
I FR�by�afhrm that I have a certl/Iters of consent to self insure '
or a ceridmate 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)
Poll y No Company . FOR APPLICANT TO FILL IN JOB
copy
Cemlied copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE 0'))
❑ _
Certified py Is byam
led the county building inspection 1 &2 Family Sq FI & & LOCALITY foil ly
NEAREST /N/)_/
department Multi family Set Ft — CROSS ST !J�'F rte. `
Date ApplicantResidential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
5
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Ree J_Light_S. IRM NAME
COMPENSATION INSURANCE „� Fret 20 v
(This section need not ba completed If the work Involved by the f. MAIL
Total No Additional ADDRESS
permit Is for one hundred dollars(5700)or lees)
I certify that in the performance of the work for which this permit CITY Tel No
is issued I shall not empIOy an ere0n manner so as to PIAN CHECK 1
become subject to the Workers ompe I n w Lighting Fixtures First 20 APPLICANT -
I I _ I -'R (- Total No Addithonal ADDRESS
Date 1 App ice RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT' -making this Certihcate of D /O 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 EG CGL-N G�
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT _6
LICENSED CONTRACTORS DECLARATION " Size 8 Type HP KW KVA or KVAR - ADDRESS ji 3 9
1 hereby affirm that I am licensed under,p revisions of Chapter 9 Over 3 to 10Ind
(commencing with Section 7000) of Division 3 of the Business and CITY .� p q7"Y Tel No
Professions Code and my license Is in full force and effect Over 10 to 50 Incl LICENSE OR !� }
Oyer 50 to 1DO Incl REG NUMBER S&3 7 w
Ck Cd
License Nu r Lit Class 00, � Over, 100 DISTRICT NO � P SSED BY O
Services Swbd MCC&Panelboards V C(L.�-�-As=✓ (cc
Contr or Date �' - 0 399 Amp Under 600V FINAL 0
❑ 400 1000 Amp Under 600 V _2'/ (�
I am exempt under Sec VALIDATION
Over 1000 Amp Or Over BDO V FINAL _ W
B&P C for this reason BRANCH CIRCUIT FEES BY d
Date 15A or 20A 120V Lighting or Recept Z_
1 To 10 Branch Circuits
Signature - -11 To 40 Branch Circuits -
❑ Exempt"for Reg Maml Elect 15A 2GA 2OBV To 277V41 Ln Mane Br0Circuits Circuits -
` L
SINGLE FAMILY Temp Power Pole&Appurtenances y
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License Law Sign with One Branch Circuit t� [[❑
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits 3;303 •TJ.�I
Code) 1 ITEMS
❑ I as owner of the property will do the work and the structure Vise Conduits&Conductors
is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)_ TOTAL 45- 75
and Professions Code) - CN 4c 15
CHE
IIIc
CONSTRUCTION LENDING AGENCY _ _ Irl
I hereby affirm that there Is a construction lending agency for the INGt
performance of the work for which this permit is Issued (Sec 3097 PERMIT FEE (Sub-Total)
Civ C)
PLAN CHECKING FEE GOCIIL�IAQ1 '11i 1/i4
Lander s Name / -
PERMIT ISSUING FEE 751b 1 H'M1 i r
Lenders Address
I certify that I he"read this application and under penalty of perjury state TOTAL FEE
that the above Information Is correct I agree to comply with all County -
ancesan w r�g n tocol wrong and hereby authorize
represent vas of his
tm the abo mentioned property '� ,
lar,i urpc SEE REVERSE FOR EXPLANATORY LANGUAGE
aIONATUR RMITfEE OTE