HomeMy Public PortalAbout5702 ROWLAND AVE_Electrical__ WORKER'S COMPENSATION DECLARATION �SA663 DPW(12-97) AJO-PLICATION FOR ELECTRICAL PERMIT
I hereby 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 BUI DING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
PJOBolicy No. Company FOR APPLICANT TO FILL IN ADDRESS g�O� I
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE$ $Ft
Wic 7X
Sq
, . . LOCALITY
—
Certified copy is filed with the county building inspection 1&2-Family, NEAREST
department. Multi-family Sq.Ft. — CROSS ST.
Date: Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. FIRMOWN NAME Aa A Gft�Ljs �j7`jlJ�fjL
COMPENSATION INSURANCE First 20 On
his section need not be completed if the work Involved b the MAIL �.®,
p y Total No. Additional ADDRESS �7
permit is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit CITY,4;�qA) �£� Tet. o.
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
Date`� Total No. Additional ADDRESS
y 1 r 3 Applicant�oeili � �
NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. 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 PPUCANT £/c�� �/L5j
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
ICa�3, G�OII�� 3T
1 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 CI 'j _ Tel.No.L� -���J
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. �L _
LICENSE OR
Over 50 to 100 Incl. REG.NUMBERrf 3s-s 0 Class' �� d
License Number L�r Lic.Class �o Over 100 DISTRICT NO. p PROCESSED BY U
l Services,Swb�di.,,tM�CC&Panelboards
Contracto Date �/ VI395?13 m nd r 00 V DATE
❑ 400-1000 Amp.Under 600 V 1-H5 VALIDATION
~
I am exempt under Sec. V
Over 1000 Amp.or Over 600 Vd
B.&P.C,for this reason FINAL
BRANCH CIRCUIT FEES BY
Date: 15A,or 20A,120V,Lighting or Recept. 4, 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
SINGLE FAMILY Temp.Power Pole&Appurtenances .:
HOME OWNER-BUILDER DECLARATION t'I�'1
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ==+ vz
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
Misc.Conduits&Conductors �Trr
I,as owner of the property,will do the work and the structure i -
ME
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) �-
and Professions Code). TOTAL '�-�'� a 85,
-+-z
CONSTRUCTION LENDING AGENCY �A,H `'°8'r
I hereby affirm that there is a construction lending agency for the �j ''`i°} 111,
performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE _
Lender's Name
PERMIT ISSUING FEE ( Q + nd.
Lender's Address r� `52 2 1 AN iT)v v 1
I certify that I have read this application and under penalty of purjury state TOTAL FEE r/
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize ,
(.pr ntatives of this County to enter upon the above-mentioned property
r'n a on purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
NATURE OF PERMITTEE DATE '