HomeMy Public PortalAbout5708 OAK AVE_Electrical_5/1/1995_WORKER'S COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to solmil
or a certificate of Worker's Compensation Insure or a certified
copy thereof (Sec. 3000 Lab. C.)
Policy No.
F, Certified copy is
❑ Certified
Date
filed with the county building inspection
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the work Involved by the
permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compe/nsation�Paws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions hapler 9
(commencing with Section 7000) of Division 3 of Business and
Professions Code, and my license is in lull for no effect.
License Number 1 ic. Class
7Contractor / Datn
LJ I am exam oder Sac.
B.&P for this reason
nate:
Signature
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions
code:
I, as owner of the property, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097,
ON. C.)
Lender's Name
Lender's Address
I certify that I have read this application and under penalty of purjury state
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and hereby authorize
representativA of this County to enter upon the above-mentioned property
for in pec on purposes.
Y/t
SIGNATURE
RE OF PERMITTEE DATE
4M19A663 DPW (12.91)
4683 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
FOR APPLICANT TO FILL IN JOB
AODgESS '% h
New Residential Bldgs. & Pools INO, EACH FEE
1 & 2 -Family, Sq. Ft. I— s $ LOCALITY
Multi -family Sq. Ft. CROSS ST.
Residential Swimming Pools ASSESSOR
Outlets: Pec. _ Light _ Sw. _
First 20
Total No. Additional
Lighting Fixtures First 20
Total No. Additional
RESIDENTIAL APPLIANCES NOT OVER 3 HP.
OTHER APPLIANCES NOT OVER 3 HP.
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVAR
Over 3 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Incl.
Over 100
Services, Swbd., MCC & Panelboards
0 - 399 Amp. Under 600 V �I
400 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
BRANCH CIRCUIT FEES
15A, or 20A, 120V, Lighting or Recept.
I To 10 Branch Circuits
I i To 40 Branch Circuits I
41 Or More Branch Circuit -
15A, 20A, 208V To 277V Lighting Br. Circuits
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)
PERMIT FEE
PLAN CHECKING FEE
PERMIT ISSUING FEE
TOTAL FEE
MAP BOOK ���i PAGE OIC PARCEL
OWNER OR
FIRM NAME VQ
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MAIL
ADDRESS y,
CITY —1d7_w, UO L -1'4
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APPLICANT
.ADDRESS
CITY
PERMIT
APPLICANT L�Ti(i9
ADDRESS
CITY
LICENSE OR
REG.NUMBER
Tel. No.
Tel. No.
T.I. No.
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APPROVALS DATE INSPECTOR'S
OWNER -BUILDER DECLARATION
SIGNATURE
TEMP. POWER' POLE ..
I hereby affirm that I am exempt from the Contractor's License Law for
UND
the following reason (Section 7031.5, Business and Professions
Code): Any city or county which requires a -permit to construct, alter,
ROUGH CONDUIT "
improve, demolish, or repair any structure, prior to its issuance, also
WIRING_ l
requires the applicant for such permit to Nle a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
FIXTURES.
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
POWER AUTHORIZED " j '^
Business and Professions Code) or that he is exempt therefrom and.
the basis for the alleged exdMptlon. • Any violation of Section 7031.5
UTILITY CO. NOTIFIED.
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by any applicant for a permit subjects the applicant to a civil penalty
FINAL :Enter on Front
of not more than five hundred dollars Woo):
NOTES
❑ I, as owner of the property will do the work, and the structure
is not intended or offered for sale.
(Sec. 7044, Business and Professions Code. The Contractor's Li-'
cense Law does not apply to an owner of property who builds or,
improves- thereon, and who does such work himself provided that
such improvements are not intended or offered for sale. If, however,
the building or Improvement Is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or
improve for the purpose of sale.)
• :•
I am exempt under Sec.
,' ••• : -
B & P.C. for this reason
'
Date
Owner