HomeMy Public PortalAbout6142 RENO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12=91) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affignihat I have"a certificate of.consept t%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 thbreof.(Sec.3800 Lab.C.)
Policy No. Company FOR APPLICANT TO.FILL IN JOB M
ADDRESS K M R&40 lemple 1C
Certified copy is hereby furnished. New.Flesidential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR /�p
MAP BOOK =40 y' PAGE�� PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Roo.]-I—Light-5—s.. OWNER OR
COMPENSATION INSURANCE 2+ FIRM NAME
First 20 MAIL
(This section need not be completed If the work Involved by:the Total No. N D ADDRESS
permit'is for one hundred dollars($100)or less.) Additional
I certify that'in the performance of the work for wliich this permit CITY K t Tet.NoA9—267-3) 4
Is issued, I shall not employ any person in any manner so as to I
become subject'to the Workers'Compensation Laws. Lighting Fixtures First 20 / A PLICANTK
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. le,A)
NOTICE TO APPLICANTi 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 A'
provisions or this permit shall be deemed revoked. Power Apparatus&.Large:Appilances APPLICANT 6�
LICENSED CONTRACTORS DECLARATION Size&Type P,KW,KVA,or KVAR ADDRESS
I hereby affirm thatJ am licensed under provisions of Chapter 9IT i 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. >_LICENSE Class
Over 50 to 100 Incl. REG.NUMBB ER d
License Number
Over 100
Lic.Class DISTRICT NO. P %BSED BY O
ry V
Servic d MC(��& ellb9�a�'ys (� Q
0-3 9S Amp. ndU800 V (� FINAL
Contractor _ Date. DATE 0
❑ 00-1'000 Amp.Under 800 V VALIDATION V
I amexempt Under Sec. Over 1000 Amp.or Over.600 V
FINAL
• d
B.&P:C.for this reason BRANCH CIRCUIT FEES BYco
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ At Li More Branch Circuits
Exemption for,Reg.Mal t.Elect. i5A 20A,2081 To 2771 Lighting Br.Circuits "V 11 4I� RBO
SINGLE FAMILY Temp.Power Pole&Appurtenances, CHECK �0 0Q
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that I am exempt from the Contractor's j_icense Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): CHANGE o 00
I,: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). , WOO-0001 9/. 5/95
CONSTRUCTION LENDING AGENCY 2141 1 AM S°22
1 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) �Q ,d
Civ.C.)
PLAN CHECKING FEE
Lender's Name '
PERMIT ISSUING FEE
Lender's Address p�
TOTAL FEE
I certify that I have read this application and under penalty of purjury'state 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 to enter upon the above-mentioned property
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
12lLfJ1 I.-s -1
GNAT RE OF PE ITTEE DATE