HomeMy Public PortalAbout6008 ROWLAND AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 72o-00196A663 DPW(72-91) APPLICATION FOR ELECTRICAL PERMIT lJ
„'' 76A663
I herebyja&Wtha 'I have a certificate of consent to self insure, 11
04,aacertiflaate of Worker's Compensation Insurance, or A certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. ,
copy thereof(§ec.3800 Lab:C.) s `
policy No. Company FOR APPLICANT TO FILL IN JOB
DDRIf �O
Certified copy Is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
1&.2-Family,Sq.Ft. y $•' $ `ILzi .
•Certified copy Is filed with the county,building inspection NEAREST
department. Multi-family Sq.Ft. CROSSST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRMENAME fyt,) vV_&%T
COMPENSATION INSURANCE
First.20 MAIL .
(This"seotion need not be completed If the work Involved by the 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 1.. �tVt .7V C leek G 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•th.e Workers'Compensation OTHER APPLIANCES:NOT OVER.3 HP. L.
provisions of the Labor Code;you must forthwith comply with such PERLMICl�NT
provisions or this permit ahall be deemed revoked. Power Apparatus&Large Appliances eC
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDIt8S LC4% CUv W-CkJ-
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. " x t
(commencing with Section 7000)of Division 3 of the Business and CITY�� �u�h C.C�t .TeI.No% AL1
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICE �' �/ q
RECL N`U B G L J CD '� Class.C.—Lo
a
Over 50 t0 100 Incl. REG.NUMBER J
S O O Over 100 DISTRICT NO. PRO D BY V
License Number Lic.Glass /�
A`' ,•,3Q -9• Services,Swbd.,MCC&Panelboards �a 4 cc
0
Contractor t-wq. W Lr e %1*ka Date .L +�g�- '0-399 Amp..Under 600 V DATE `
❑ Am exempt under Sec. 400-1000 Amp.Under 600 V —� W
13—
I Qr • VALIDATION
Over 1000 Amp.or Over 600 V FINAL I Il
B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z
Date: 15A,or20A,12OV,Lighting or Recept.
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 Tem Power Pole&Appurtenances f '; a -
HOME OWNER-BUILDER DECLARATION p• Ci 1144. ea
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit —K 5 .-.—
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits `d3)1 '�" a
Code): I '(T
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors `` -- 0
m-94
is not intended or offered.for sale(Section 7044, Business Other(See Complete Fee Schedule) 31 IL '—'
and Professions Code.). , CHECK BID.Oj 4
CONSTRUCTION LENDING AGENCY t`,HAH6E .00
I 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)
Civ.C. Cutl2-'0.Il!J I U: 41 0.°
PLAN CHECKING FEE _
Lender's Name LC�e I
PERMIT ISSUING FEE
Lender's Address �2 9
I certify that I have read this application and under penalty of purjury state TOTAL FEE �
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 insp ion p r es. f/ SEE REVERSE FOR EXPLANATORY LANGUAGE,
t� `Q
SIGNAJJREfFfERmrrTEE DATE