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HomeMy Public PortalAbout10835 ARROWOOD ST_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW(12-9t) 76A663 APP U CAMN F®R EL ECTMICAL PERNT �J I hereby affirm that I have a certificate of consent to self insure, t or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANdELESµ DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) Policy No.1ATZ706 Company FOR APPLICANT TO FILL IN ICE ADDRESS Y(9Q F-1Certifiedcopy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE — $ $ LOCALITY Certified co is filed with the count uildin Ins echo 1 &2-Family,Sq.Ff. copy Y 9 P NEAREST department. Multi-family Sq.Ft. CROSS ST. zv P ` C�w1 v Date �1I /� Applicant esidential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.A)Light� Sw.� FORM WNER OR ef 77 COMPENSATION INSURANCE First 20 gn (This section need not be completed if the work involved by the MAIL permit is for one hundred dollars($100)or less.) Total No C7 Additional ADDRESS 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 t0 f PLAN CH CK become-subject to the Workers'Compensation Laws. . Lighting Fixtulll-. First 20 APPLICANT Total No Lek Additional 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 the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 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 Incl. (commencing with Section 7000) of Division 3 of the Business and CITY (-teqTel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. gir LICENSE / L/- Class.. Over 50 t0 100 Incl. REG.NUMBER bIs /,/`� Over 100 a License Number p L ` Lic.Class DISTRICT NO. P C SED By Q ` r Services,Swbd.,MCC&Panelboards cc ate `r `�' 0-399 Amp.Under 600 V F NAL DATE ' O ❑ 400-1000 Amp.Under 600 V VALIDATION V I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL UJ B.&P.C.for this reason BRANCH CIRCUIT FEES BY 0- CO ate: 15A,or 20A, 120V,Lighting or Recept. Z 1To 10 Branch Circuits Signatur 11 To 40 Branch Circuits 41 Or More Branch Circuits ❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits ,& ACCT n V SINGLE FAMILY Temp.Power Pole&Appurtenances .,_, HOME OWNER-BUILDER DECLARATION 3303 77.30 1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit T i for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 1 ITEMS lS Code): F1 1, Conduits&Conductors TOTAL 77 -30 I, as owner of the property,will do the work and the structure it is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) CHECK 77.30 and Professions Code). D CHANGE .00 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, PERMIT FEE . (Sub-Total) a 0000-00011 a/11°,!fi Civ. C.) PLAN CHECKING FEE 5350 1 AC10s07 Lender's Name PERMIT ISSUING FEE d Lender's Address /�► y I certify that I haver this application and under penalty of purjury state TOTAL FEE / �i that the above or ation is correct. I agree to comply with all County ordinances d St laws regulating Electrical wiring,and hereby authorize rese tives this County to enter upon the above-mentioned property or i pectio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE e:- _ �k SIGNATURE OF PERMITTEE DATE p� p �a�p® q p WORKER'S COMPENSATION DECLARATION ,_ 20-0019 DPW 9/89 APPLICATION p51np ��p y��®II CI ®� �L��ls II TG��d�ill� PERMIT 76A663 P P L� /tib II 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 BUILDING AND SAFETY DIV. copy thereof(Sec.,3800 Lab.C.)' ; Policy No. Company FOR APPLICANT TO FILL IN JOB uJ ADDRESS Certified co is hereby furnished. EACH NO. FEE PY Y New Residential Bldgs.&Pools LOCALITY h �f ❑ 1&2-Family,Sq.Ft. $ — $ Certified copy is filed with the county building inspection _ NEAREST 1 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.'* OWNER OR COMPENSATION INSURANCE FIRM NAME First 20 ` (This section need not be completed if the work involved by the t MAIL permit is for one hundred dollars($100)or less.) Total No. Additional w ADDRESS (1�%' � OLv 10,7" I certify that in the performance of the work for which this permit CITY T \_ Tel.No. is issued, I shall not employ any perso in any mann so as to Lighting Fixtures First 20 PLAN CHECK become subject to the.Workers'Compe soli Law 9 9 - APPLICANT _ Total No. Additional 1 Applica ADDRESS Date �"� 120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, a making this Certificate of 15 OR 20A, y CITY Tel.No. Exemption;you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH rovisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT p P Y P Y APPLICANT , Vt provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >_ LICENSED CONTRACTORS DECLARATIONADDRESS 3((� CL I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH CL (commencing with Section 7000) of Division*3 of the Business and CITY���©�l� Ido -SSWL-2-'20 0 Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR O 11 44;.J q /r� Power Apparatus&Large Appliances REG.NUMBER .�s class.�y O License Number ��26/ Lic.Class � 0 Size&Type HP,KW,KVA,Or KVAR DISTRICT NO. PROCESSED BY Up to 3 Incl. � �� O��� Over 3 to 10 Incl. FINAL co Contract0 DATE Over 10 to 50 Incl. Z ❑ 1 am exempt under Sec. Over 50 to 100 Incl. v VALIDATION Over 100 FINAL B.&P.C.for this reason BY Ser'ces,Swbd.,MCC&Panelboards , Date: d 200 Amp.Under 600 V Signature 1 -1000 Amp:Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. +•t SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 'Sign with One Branch Circuit ' 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 _ ? ':;7 _, ,•_ Code): ❑ ! °=i:'Y I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ® =;AL and Professions Code). - - .-r•s; ...'iii'5.•:'t,. _ - .. 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, PERMIT FEE (Sub-Total) U - Civ.C.) PLAN CHECKING'FEE Lender's Name PERMIT ISSUING FEE IN Lender's Address _ ✓!S I certify that I have read this application and state that the above TOTAL FEE �! information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize re sentatives of is County to enter upon the above-mentioned, o rty r i cc io s. _ SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE