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Home My Public Portal About9925 BOGUE ST_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 CE-806G E APPLICATBON FOR ELECTRICAL PERMIT {� I hereby affirm that I have a certificate of consent to self insure, u or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy,thereof(Sec. 3800,Lab.C.) r7 _ p/�, Policy No.'- b D Company .l - /7 FOR APPLICANT TO FILL IN JOB o� ❑ Certified copy is hereby furnished.. New Residential Bldgs.&Pools EACH NO. FEE ADbRESS 1 & 2-Family,Sq.Ft. $ — $ LOCALITY am ❑ Certified copy is filed with the county building inspection — depart ent. Multi-family Sq.Ft. NEAREST CROSS ST. pv Date Applicant Residential Swimming Pools OWNER OR - FIRM NAME rs YL'UR ;IU CER IFICATE OF EXEMPTION FROM WORKERS' � � / AMAIL DDRESS COMPENSATION INSURANCE Outlets:Rec Light Sw. (a This section need not be completed+if the work involved b the First 20 Af ( y Total No.� Additional CITY Tel.No. permit is for one hundred dollars($100)or less.) PLAN CHECK I certify that in the performance of the work for which this permit APPLICANT is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 �� ADDRESS Additional Total No. CITY Tel.No. Date Applicant. Fixed Appliances Not Over 1 HP rPERMIT NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven — Dryer _ W.M. ADDRESS/ f provisions or this permit shall be deemed revoked. Top — FAU W.H. CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ 1 I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE Disp. — Room Air Cond. � REG.NUMBER Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. P SED BY Size& Type HP,KW,KVA,or KVARG� o License Number a Lie.Class Up to 1 Incl. FINAL V D / Over 1 to 101ncl. DATE �` n VALIDATION M Contractor Date / Over 10 to 50 Incl. V U ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W �- B.&P:C. for this reason Over 100 C/) b Services,Swbd.,MCC& Panelboards ® _Z �� 0- 200 Amp.Under 600 V Signature� !( 201 - 1000 Amp.Under 600 V ' ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole & Appurtenances HOME OWNER-BUILDER DECLARATION. Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law I for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 3:3 4-70 = �z ❑ Misc.Conduits& Conductors .l. I,as owner of the property,will do the work and the structure i' is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 1 'L°='.;n and Professions Code). TO 1 AL' -�.s_ e CONSTRUCTION LENDING AGENCY CHECK k't_.•rK 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) f• llV� _O=( Civ. C.). PLAN CHECKING FEE Lender's Name I 13(301€-1_101 W. �;,,.•�'�'� PERMIT ISSUING FEE /�i Lender's Address f f5p i H![ 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 representatives of this County to enter upon the above-mentioned proper r inspection purposes. j SEE REVERSE FOR EXPLANATORY LANGUAGE J Si6natcrre o-V PerNittM Date WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT 76A66 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 WORK91 BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY El $Ft Sq. . — $ G Certified copy is filed with the county building inspection 1 &2-Family, _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR PAGENER OR PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME Q 64 LC COMPENSATION INSURANCE First 20 (This section need not be completed if the work involved by the MAIL s 2 permit is for one hundred dollars($100)or less.) Total No. Additional r /7 I certify that in the performance of the work for which this permit CITY Ae -e 1 Tel N'-/,P 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 Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT Aef� provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No, 0 Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Clcc Power Apparatus&Large Appliances REG.NUMBER ass. License Number Lic.Glass Size&Type HP,KW,KVA,or KVAR DISTRICT NO. P O SED BY Up to 3 Incl. W Contractor Date Over 3 to 10 Incl DATE Z ❑ Over 10 to 50 Incl. I am exempt under Sec. Over 50 to 100 Incl. VALIDATION FINAL B.&P.C.for this reason Over 100 BY Service S C .t C&Panelboards y Date: ' 0 Am nder 600 V ( /i Signature 201 •1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY - Temp.Power Pole&Appurtenances - HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 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 '`.L':r' - Code): ar i Conduts&Conductors r- I,as owner of the property,.will do the work and the structure Misc. is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 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, PERMIT FEE (Sub-Total) Civ. C.) p PLAN CHECKING FEE Lender's Name ��` - �� PERMIT ISSUING FEE �� "'"` � •" Lender's Address O — o I certify that I have read this application an state that the abov TA TAL FEE �+�J information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this m Co y to enter upon the above-mentioned pro y or inspection roses. SEE REVERSE FOR EXPLANATORY LANGUAGE SI RE OF APPLICANT OR AGENT DTE WORKER'S COMPENSATION DECLARATION 20-0019 76A663 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, J 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 ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ❑ $ _ $ LOCALITY Certified co Is filed with the count building inspection 1 &2-Family,Sq.Ft. PY Y 9 P — NEAREST 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 g FIRM NAME (This section need not be completed if the work involved by the First 20 MAILADDREss permit is for one hundred dollars($100)or less.) Total No. Additional 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 Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption, you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT P Y P Y APPLICANT } provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH 0- LICENSED LICENSED CONTRACTORS DECLARATION ADDRESS 0 I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH V (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. C-) Professions Code,and my license is in full force and effect. LLJ RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR J Class Power Apparatus&Large Appliances REG.NUMBER LL License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY } Up to 3 Incl. Q Contractor Date Over 3 to 10 Incl. FINE Over 10 to 50 Incl. d El I am exempt under Sec. Over 50 to 100 Incl. VALIDATION c FINAL Over 100 c B.&P.C.for this reason BY U.1 Services,Swbd.,MCC&Panelboards Date: 0-200 Amp. Under 600 V Signature 201 -1000 Amp. Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ❑ 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) , 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, PERMIT FEE (Sub-Total) Civ. C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address 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 representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE