HomeMy Public PortalAbout6026 PRIMROSE AVE_Electrical__ W.ORKER�S COMPENSATION DECLARATION •' za°019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
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I,hereby.affi�m.ttat hhave a certificate,of conserit to self insure,
or a cntlflcate of Worker's Compehsation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC,WORKS BUILDING AND SAFETY DIV.
Copy#hereof(Sec.3800 Lab.C.) ,
.Policy No:. Company FOR APPLICANT TO FILL IN JOB /
ADDRESS �O�(v
Certified copy is hereby furnished. NOW Residential Bldgs.&Poo s NO. EACH FEE
$ LOCALITY �
❑ 1$2-Family,Sq.Ft.
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant 'Residential Swimming Pools ASSESSOR
MAP BOOK& PAGE fes` -31 PARCEL DI
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw: OWNER OR
COMPENSATION INSURANCE FIRM NAME ��/,
(This section need not be completed if the work Involved by the First 20 MAIL
permit is for one hundred dollars(5100).or less.) Total No. Additional ADDRESS �o
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 mariner 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
. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
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 CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to.100 Incl. RIEEG.NUMBER Class. d
License Number LIC.Class Over 100 DISTRICT NO, p P EBBED BY V
Services,Swbd.,MCC&PanelboardsDO L�may' IZ
Contractor Date 6-399 Amp.Under 600 V DATE O
❑ I am exempt under Sec.. 400-1000 Amp..Under 600 V V
F2-rAl VALIDATION W
Over 1000 Amp.or'Over 600 V FINAL d
B.&P.C.for this reason BRANCH CIRCUIT FEES BY C0
Date: 15A,.or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 2
SINGLE FAMILY Temp.Power Pole&Appurtenances. ACGTA
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 3303 246.92
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 1 ITEMS
Code):
1 owner of the property,will do the work and the structure Misc.Conduits&.Conductors TOTAL d-d�4 m
92
is not Intended or offered for sale(Section 7044, Business Other(See.Complete Fee Schedule) , HE{,•r� (�of1?
and Professions Code).
CONSTRUCTION LENDING AGENCY CHANGE .00
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) 0000"0001 5/28/96
PLAN CHECKING FEE 6605 1 AM11-016
Lender's Name
PERMIT ISSUING FEE 0
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE1��
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
%9IGNATURL1OF PERMITTEE DAT