HomeMy Public PortalAbout5617 SANTA ANITA AVE_Electrical__ WORKERS COMPENSATION DECLARATION 77SAA663 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate-of consent to.self'Insure,
or a ertificate,pf Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copyFhetbof(Sec.3800 Lab..Com/.)
Policy No. 1' s0� '��ompany Xezwo FOR APPLICANT TO FILL IN JOB
ADORE
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Certified copy is heFeby furnished. .New Residential Bidgs.&Pools NO. EACH FEE LOCALITY
❑ 1&2-Family,Sq.Ft. — $ $ -
CertlOed copy is filed with the county building in action NEAREST
department. Multi-family Sq.Ft. 9 CROSS ST.
Date /� Applic Residential Swimming Pool
t=�3+3o assEssoR
MAP BOOK �� AOE OaD PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME
COMPENSATION INSURANCE
First 20 MAIL
(This section need not be completed If the work Involved by the Total No. Additional ADDRESS C ✓ .
permit Is for one hundred dollars($7000)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 pplicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICAN 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 suchRMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances PPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I'hereby affirm that I am licensed under'provisions of Chapter 9 Over 3 to 10 Ince. r o
(commencing with Section 7.000)of Division'3•of the Business and CITY 2 5,e-3 To I.No. �+
Professions Code,and my license is In full force and effect'. Over 10 to 50 Incl..
LICENSE OR Class Q.
A+ / Over 50 t0 100 IIICI. REO.NUMBER 2 $ Ca7
License Number'' Z v C/�l a Over 100 DISTRICT NO: P C SED BY V
Lic:Class ` O
Services,Swbd.,MCC&Panelboards
/—:��� 0-399 Amp.Under 600 V FINAL
Contractor Date DATE I—
❑ 400-1.000 Amp.Under 600 V —C W
I am exempt u der Sec. Over 1000 Amp.or Over 600 V VALIDATION
P FINAL (L
B.&P.C.for this reasonBY U)
BRANCH CIRCUIT FEES
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits ri
El4.1.Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A„20A,208V To 277V Lighting.Br..Circuits ,, a
t�t•C T a ir
SINGLE FAMILY Temp.Power Pole&Appurtenances = ., T
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit s{-3v _tom. j
I hereby affirm that I am exempt from the Contractor's License Law r
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch CircuitsE0.
Code): _
❑ 1,as owner of the propert 'fid the structure Misc.Conduits&Conductors TOTAL x'52 m 30
is not intended or d for sale(Section 7044, Business Other(See Complete Fee Schedule) ?'lC► ya ' i
and Profession . ode). .
y-��jj�{g�• ,13t1
NSTRUCTION LENDING AGENCY
I hereby affir hat there is a construction lending agency.for the /
performanc f the work for.which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) ya� DOCIII-0001 1/ -5/94
Civ.C.)
PLAN CHECKING FEE 3310 # 4M 948
Lender' Name
PERMIT ISSUING FEE a d
Lender's Address G
I certify that I have read this application and under penalty of purjury state TOTAL FEE 70
9. 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 inspection pure s SEE REVERSE FOR EXPLANATORY LANGUAGE
NA RE OF PERMITTEE DATE