HomeMy Public PortalAbout5560 ROBINHOOD AVE_Electrical__ 11 'WORKER'S COMPENSATIONDECLARATION 20oo,oDPW(12-at) APPLICATION FOR ELECTRICAL PERMIT
I hereby afflrn?that I have a certificate d consent to self Insure, 76AEB3
or a cortlflcate of Worker's Compenaatlon Insurance, or a certlfled COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof,(Seo'3600 Lab. C.)
PoOcy No. i' ti Company FOR APPLICANT To PaJ aV � D �!� }(V V D . G.
❑ Certfl4d copy Is hereby fum hed. New Reeldontiai Bldgs.S Pooh NO. EACH FEE
— s s LOCALITY
❑ Certffled ccpy Is flied with the county building lr4pectkm 1 &2 fam4y,Sq.Ft- NEAREST
dNwtmwTt Murd-famrly Sq.Ft. — CcaoaS ST.
Date Reeldenba}SwlmmIng Pools
ee�� M/p 90of< pI,OE pAf7C8
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rao. Light i�Sw._� GyhTETi OA v�`O�/ e�
COMPENSATION INSURANCE F RL NAME l71
Rrat 20
(This section need hot be completed H the work Involved by the AWL
Total No. _ Addttloral MAJL S
Permit la for one hundred dollars(8100)or Isere.)
I certify that In the performanoe of the work for which this permit CITY TOL No.
Is Issued, I shall not employ any person In any manrler so as to PLAN oto
become subject to the Work"' Compensation Laws. Lighting Fixtures Brei 20 APPLICANT
Total No. Additional ADDRESS
Applkcsnt RESIDEN LAL APPLIANCES NOT OVER 3 HP.
NOTE TO,APPLICANT: If, after makl art cats of CITY Tel-Na
Exemptlon,you should become subject to the Workers' CompensWlon OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such Parr
provisions or this permit shall be deemed revoked. Power Apparatus S Large Appliance° APPLICANT
LICENSED CONTRACTORS DECLARATION Size S Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under-provisions of Chapter B Over 3 to 10 hid.
(commencing with Section 70DO) of Olvlolon 3 of the Business and CITY Tel.No
Profeealons Code, and my license Ia In full force and effect. Oyer 10 to 60 Ind. >,
Over 60 to 100 Ind. F BER Com.
Over 100 DteTT1�cT
LJoerree Number LbGale Over
Ga
Swylcee,Swbd.,MCC&Pan om-da vv
Contractor Dade 0-399 Amp.Under 900 V DATE O~� /
Elder I am exempt unSeo. 400-1000 Amp.Under 900 V VALJDATHNi W
Over 1000 Amp.or Over 900 V FINAL d
B.hP.G.for this reasonBY
BRANCH CIRCUIT FEES Z
Date: 16A,or 20A,120V,Lighting or Recept
1 To 10 Branch Clroults
Signature 11 To 40 oronah Circuits
41 Or F-1 Exemption for Reg.Matnt Elect 16A,20A,200V To 277V More Cfaurs A1r rT
SINGLE FAMILY Temp.Power Pole S Appurtenances rn.41 .i
HOME OWNER-BUILDER DECLARATION ��with One Branch Gtrwlt �^
I hereby affirm that I am exempt from the Contractor's LJcense Law 7 7 Gv
for the following reason (Section 7031.6, Business and Professions AddItional Sign Branch Clroults
Code): �l1 i}�
❑ I, as owner of the property,will do the work and the etruotlsnd
ure Mo.Conduits a Couctor* I T OTAL 49 -80
Is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). R `�4ECiY, 4f{
CONSTRLK:TION LENDING AGENCY 4TitYiL�
I hereby affirm that there Is a constructloh lending agency for the
performance of.the work for which this permit Is Issued (Seo. 3097, pERMrr FEF (Sub-Totaf) 7,3
Ci 4Ii 1 `�4
Ch. C.) 1 .J 19/
PLAN CHECKING FEE
Lender's Name 5214 1 PM 5:07
PERMrr ISSUING FEE
Lender's Address
I cert}fy that I have read this application and under penalty of perjury state TOTAL FEE
that the above Information is correaL I agree to oompiy with all County
ordlnancee and State laws regulating Electrical wldng,end hereby authorbm
represerttatfvee of this County to eater upon the sbove-rnaROpnsd property
SEE REVERSE FOR EXPLANATORY LANGUAGE
�6- a
MNATURE OF DATE .