HomeMy Public PortalAbout5551 PARMERTON AVE_Electrical_11/18/1992_ WORKCOMPENSATION DECLARATION 20 oO19 DPW(1291) APPLICATION FOjR ELECTRICAL PERMIT I1
78A863
I hgreby affirm ThattI have have a card Ocata of consent to self Insure �
or a cart 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) t^ _ •r�.�
Pulley No Company FOR APPLICANT TO FILL IN JO
DRESS ESS
dletlhwpy Is hereby furnished ` New Residential Bldgs &Pools NO EACH FEE LOCALITY
ified
Certcopy Is filed with the my budding inspection 1 8 2 Family SFt $ $
_d11epartmentFp , Multi family Sq Ft CRROSS 3T �
Date �r lb�It Applicant Resldenttal Swimming Poole tr ASSESSOR �f�
r ti = MAP BOOK ` PAGE PAl10E1'•`•'
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Roc Light s t O OWNER OR
Sw
r C, ` COMPENSATION INSURANCE .1 '
(This
section need not be completed rt the work Involve tl.by the First 20 RPM NAME
MAIL
pe rmll Is for one hundred dollars(&100)'or lase) Total No AddNonal - ADDRESS 7tx_ q_,
I certify that In the performance of the work for which this permit _ CITY Tel No
Is issued I shall not employ any person In any manner so as to PIAN CHECK
become subject to the Workers Compensation Laws Lighting Fqures _ First 20 APPLICANTL11,01 A.
Total No Addumnal ADDRESS W
Date' - Applicant
CES NOT OVER 3 HP
-�
NOTICE TAPPLICANT
after making this Certificate of CITY � TePNo 4qZ Z7
Exemyption ouishould become
RESIDENTIAL APPLIANL subject to the Workers Compensation OTHER'APPLIANCES NOT OVER 3 HP
Piovisions,of•ths Labor Code you must forthwrth'comply with sucli PERMIT LAwL
provisions or this permit shell be deemed revoked Power Apparatus&Large Appliances APPLICANT.
°" LICENSED CONTRACTORS DECLARATION Sae&Type HP KW KVA or KVAR ADDRESS _
I mheretiy'affirm lhat'I am licensed under'proviaions�of Chapter 9 Over 3 to 10 Incl
(comencmg with Section 7000) of Division 3 of the Business and CITY Tel No
Professions Code and my license Is In full force and effect Over 10 to 50 Ind
LJCENSE OR I CB9e ��
Over$p to 100 RCI REG NUMBER d
0
License Number /� LIC Class DVer 100 DISTRICT NO p PROyyyyyCCCCFEEES//SE''p__B''Y-- O
" 1p 11 Services Swbd MCC&Penelboerds
Contractor Date I\`I�Z 0 399 Amp Under 600 V SATE O
F-1I am exempt under Sec 5 400 1000 Amp Under 600V - -q
Over 1000 Amp or Over 600 V RNAL Over
W
' B&P C for this reason BRANCH CIRCUIT FEES _ BY
to 15A or 20A 120V Lighting or Recept _ 4 Z
A 1 To 10 Branch Circuits
Signature i 1 To 40 Branch Caamt5
41
Exemption for Fag Mamt Electcuits
15A 20A 208V To 2771 r More Br ch Circ
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit' k 3307 55. 5
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) l ITEP9S
❑ as owner of the property will do the work and the structure Mlsc Conduits&Conductors TOTAL 55- 35
Is not Intended ar offered for sale (Section 7044 Business Other(See Complete Fee Schedule)_ 1 V n1. _
and Professions Code) _ _ CHECK - 5j,35
CONSTRUCTION LENDING AGENCY CHANGE .0[I
I hereby affirm that tFere is a construction lending agency for the
performance of the work for which,lhis permit Is Issued (Sac 3097 PERMIT FEE (Sub Total)
Civ C)
PLAN CHECKING FEE 9.� _ _ _ WW-0001 11/1151/92
Lander s Name • 656 1 ' AM 8:53
(-it PERMIT ISSUING FEE
Lenders Address ' I , t
!,certify that I have read this application and under penalty of purjury,state TOTAL FEE
that the above Information rs correct I agree to comply with all County -
ordinancesendStatelawsregulatingElectricalwiring and hereby authorize `
representatives of This County to enter upon the above menboned property
Inspecflon�purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
N6E OF PERMITTEE PATE , �