HomeMy Public PortalAbout5812 ROWLAND AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT Ll
I hereby affirm that I have a certificate of consent to self insure, 76A663
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.3800 Lgb.:C') ►
P❑OIi.V N0. Company FOR APPLICANT TO FILL IN ADDRESS
S'78(2 g, P-ot,5N
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY G
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
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OR
Outlets:Rec.__L_Light__J_Sw. FFIIRMENRAME Z4/7—
G��
COMPENSATION INSURANCE First 20 /
(This section need not be completed If the work Involved by the ADDRESS ,A,11
permit is for one hundred dollars($100)or less.) Total No. 3 Additional S��2. I\ K -w
I certify that in the performance of the work for which this permit CITY •�� Com G� 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 �"� 9 Applicant
NOTICE TO APPLICANT: If, aft m ting this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No.
Exemption,you should become subject to he Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT {� n��lAS �
p p y Power Apparatus&Large Appliances APPLICANT 1'C�
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Siz &Type HP,KW,KVA,or KVAR ADDRESS ZZ
I hereby affirm that I am licensed under provisions of Chapter 9 �(— Over 3 to 10 Incl. 7-15
(commencing with Section 7000)of Division 3 of the Business and Over 10 to 50 Incl. CITY �,1p�Cj Tel.No.
Professions Code,and my license is in full force and effect. LICENSE OR cY�
Over 50 to 100 Incl. REG.NUMBER Class. 6.--[4O a
Q Over 100 DISTRICT NO. P O SED BY O
License Number Lic.Class 4—to V
t��1 Servic SSwwt�d�C P el ards
Contractor « � ` Date 16—L7 /� u-s98 Amp.Un��O V FINAL �r Q
DATE
❑ 6 /400-1000 Amp.Under 600 V v6J •(/GI VALIDATION V
I am exempt under Sec. Over 1000 Amp.or Over 600 VW
FINAL
B.&P.C.for this reason RANCH 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
t
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �t- �A
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 3303 67.6`j
Code): _
r ,
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1. � tl:•��
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) ® I E!(AL 1 o 60
and Professions Code).
t:HcCE'+ u!a 4�I�
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CHANGE .0D
performance of the work for which this permit is issued(Sec. 3097,. PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE C1=C1Q0'01 7/19/51
Lender's Nam
PERMIT ISSUING FEE 1177; 1 Ari va 15,
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE O
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 inspe I n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-(9-93
SIGNARE OFA RMITr E DATE