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WORKER'S COMPENSATION DECLARATION 200019 DPW(12=91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I her9by affirm that I have a certificate of consent to 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 thereof(Sec.3-800 Lab.C.) {� ;Lr
Policy No. . 7 Z Companyt � r� / `'�D FOR APPLICANT TO FILL IN JOB
ADDRESS O3O '(',) .. L
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. $EACH $ FEE LOCALITY Ci
Certified copy is filed with the county b ding inspection 1&2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. �l 6 s o CROSS ST..
QResidential Swimming Pools ASSESSOR
Date ,J �� Applicant MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM ORKERS' OWNER OR J C
COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM NAME
First 20 MAIL:
(This section need not.be completed if the work Involved by tho Total No: Additional ADDRESS
permit Is for one hundred dollars($100)or less.)
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 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 �'�Q
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT t�E
LICENSED CONTRACTORS DECLARATION Size&&Type HP. KVAer 3 to U n�R ADDRESS Z 3 7-�( �j. L t.S 17
1 hereby affirm that ['am licensed under provisions of Chapter 9Vo
(commencing.with Section 7000)of Division 3 of the Business and CITYe f Ll Tel.No. )/L)
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. /, ffc
Over 50 to 100 Incl. REGNUMBER S�' 7 Glass C O
Over 100 DISTRICT NO. C SED.BY
License Number�✓ r- Lid.Class P G / Q �D p �
Services,Sw MC anelboards d
FINAL 0
Cont r l� e+ Date ^ 00 V DATE. F-
400
400•-1000 Amp.Under 600 V (�G
0 I am exempt under Sec. VALIDATION�` � OW.
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z
Dat : 15A,or 20A,120V,Lighting or Recept. _
1 To 10 Branch Circuits
$Ignature: 11 To 40 Branch Circuits a
41 Or More Branch Circuits ✓% :`
Exemption for Reg.MainL_Elect. 15A;20A,208V To 277V Lighting Be.Circuits ;• i t
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �+�+
T e
Sign with One Branch Circuit A44V
• 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 3307 790.35
Code):
QI,as owner of the property,will dothe work and the structure Misc.Conduits&Conductors •1 ITEMS
Is not intended or offered for sales(Section 7044, Business er See Complete Fee Schedule).,-- TOTAL 790.35
and Professions Code)..
CONSTRUCTION LENDING AGENCY CHECK 794335
I hereby affirm that there Is a construction lending agency for the CHANGE .00
performance of the work.for which this permit is issued(Seo. 3097, PERMIT FEE (Sub-Total) b
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 6546 1 Aft 9!01
Lender's Address
1 certify that I have read this application and under penalty of purjury state TOTAL FEE �90,
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
e
for inspection purposes. SEE REVERSE.F.OR EXPLANATORY LANGUAGE
SIGNATURE OF PEFr DATE