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Home My Public Portal About9974 BOGUE ST_Electrical__ WORKERS' COMPENSATION DECLARATION :76A66vDPW 3is7 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm, tF�t I have a certificate of cons n' to self -ce eo�6G /°1 nsurerp�a certificate eef'Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab C ) Policy No Company FOR APPLICANT TO FILL IN JOB WGN E ❑ ADDRESS 9`61711A Certified copy is hereby furnished New Residential Bldgs. 8 Pools EACH NO FEE �r ❑Certified copy is filed with the county building inspec- I.& 2-Family, Sq. Ft $ — $ LOCALITY TEM Ft-F- G�'1 tion department Multi-family Sq. Ft. — NEAREST CROSS ST Residential Swimming Pools OWNER OR Date Applicant �+ ��1Drt2SD� II NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Recd QLight 3 3 FMAIL C, COMPENSATION INSURANCE Outlets: ADDRESSME f�S �•�O�/�' First 20 (This section need not be completed if the work involved by Total No. I r Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Corinpe sation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel No Date +2 Applicant Fixed Appliances Over 1 HP PERMIT NOTICE TO APPLICANT. If, after making is Certificate of APPLICATION DOME c� Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven- — Dryer —W.M.— ADDRESS I�3j� ./`/'A►fJ ' with comply with such provisions or This permit shall be Top — FAU —W.H — f � r deemed'revoked. CITY C u�TE- Tel No. Qt(2. "01 Hood — Fan —Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR 6 r 6 I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond — REG. NUMBER Class (commencing with Section 7000)of Division 3 of the Business Power Apparatus•& Large Appliances DISTRICT NO POC Y a and Professions Code,and my license is in full force and effect O Size &Type HP; KW, KVA, or KVAR O License Number Lic Class Up to 1 Incl. FINAL f, Over 1 to 10 Incl. DATE ` LIDATION cc Date Over 10 to 50 Incl. FINAL O ❑ .I am exempt under Sec. Over 50 to 100 Inc. gy U W B.&P.C. for this reason Over 100 d Services, Swbd., MCC & Panelboards , U) Date: "0- 200 Amp. Under'600 V Z Signature 201 - 1000 Amp. Under 600 V ElExemption 1000 Amp or Over 600 V Exemption for Reg .Maint .Elect SINGLE FAMILY Tem Power Pole &Appurtenances i _ HOME OWNER-BUILDER DECLARATION p' pp I hereby affirm That 1 am exempt from the Contractor's License Sign with One Branch Circuit Cl •�.l eH Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits #7 301.10 Professions Code)' I ITEMS, [DI, as owner of the property, will dMisc Conduits&Conductors o the work-and the 30 - 10 „ structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— ® TOTAL 30 e 10 Business and Professions Code). CHECK } r — t CONSTRUCTION LENDING AGENCY � _ I hereby affirm that there is a construction lending agency for itHANi3E ,ljf E the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE 0000-0001 2/231911 i Lender's Name PERMIT ISSUING FEE '7100 1 AM G'ir Lender's Address 1 certify that I have read this application and state that the TOTAL FEE IC above information is correct 1 agree to comply with all County ordinances and State jaws regulating Electrical wiring , and vg hereby thorize re resentatives of this County to enter upon th menti d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE YL O Sigriatureo ermittee Date Os J• WORKERS' COMPENSATION DECLARATION CE-806G '10i81 I.}.he,eby',affirm that I have a certificate of consent to self insure, APPLICATION FOR. ELECTRICAL PERMIT a• dS' aicertificate of Workers' Compensation Insurance,or a certified'`. COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec 38 ab C) L•; " �o. S `Ili Policy NO Company FOR APPLICANT,TOjFILL IN.,, JOB Certified copy is hereb furnished71 EACH' NO FEE ADDRESS tw Y F New.Residential Bldgs &'Pools Certified c y is,filed with the county building inspec n 1 & 2-Family,Sq Ft $• — $ '_ LOCALITY dep tmen .'r .'Multi-family Sq.Ft. NROS SST _ 'CROSS ST Date •f' Applicant v✓ ,Residential Swi mg Pools' OWNER OR -z• ! .., •a- •. " ., r 'FIRM NAME ' C RTIF.I AlE_ F.EXEMPTION FROM WO_R RS' } MAIL { i C PENSATION;INSURQNCE Outlets Red Light Sw ADDRESS :.">' First Thi need not be completed if the;work involved by:the CITY '._ C Tel No ' permit is for one hundred dollars.($100),,or less.) Total No ; Additional ,' ,• .-, '' PLAN CHEC I certify that,in'the performance of the work for whichlthis,permit } ,- :. APPLICANT K;• *' �•,., is,issued,.I shall not`employ,any,person in any,manner so as,to ' tiec'ome s;U. t,to the Workers''Cibn e ation Laws. Lighting Fixtures• ' First 20 ADDRESS'.- ' Additional ,• -Total No CITY Tel No Date Applicant Fixed Appliances Not Over 1 HP. PERMIT " NOTICE 'TO' APPLICANT 'If, 'after making;,this Certificate of (�� Exemption,, should become sublect•to•the Workers'Compensatio '' Range! Heater_ DW,' APPLICANT. Jr ADDRESS" provisions of the Lab o` Code;you must forthwith comply'with such_' ' ', Oven'_,.Dryer — 'W M.''_•',` � provisions-or this'permit-:shall be deemed revoked " , Top FAU' WH ' I LICENSED CONTRACTORS DECLARATION CITY Tel No Hood Fan Other_^ �� ` I hereby,affirm that I am licensedtunder,provisions''of•-Chapter;9 Disp Room.Air Cond` LICENSE OR ^�� Class (commencing with Section 7000) of "vision'3 of the Bu6n s and ;' REG-NUMBER NUMBER '.',Professions Code`and my'license is in full force'and effect Power Apparatus& Large Appliances . ,T 'DISTRICT NO PROCESS D BY . Size''& Type HP,KW,KVA;or KVAR License Number Lic Class - Up to 1-Incl - FINAL - Over 1 to'10 Incl DATE• F a Contractor �' :Date' 7i _ ,DATION _ 0 ❑. Over'10 to 50 Incl' FINAL I am exempt un er Sec Over 50'to 100 Inc. BY - LU B&P C for this reason' Over:100 Services,Sw' ,MCO&-Panelboards �- 7- ,Date' ,Date' 0-200 Amp'Under 600 V'qP� ��'• - ' r,^ - - . 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 Circwt ' hereby affirm that I am exempt from the Contractor's License Law, } , u for the following reason(Section 7031.5,,Busines§ and Professions Additional Sign,Branch Circuits Code)". �' =` viMisc Conduits & Conductors ["as owner of the property,will do the work and the structure s'not intended'or offered'fdr 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'wor,k for"which this permd is issued(Sec 3097; pERMIT'FEE. - ,(Sub TOta1) ' Civ C) - PLAN CHECKING•FEE, a' rl (moi .t li iTl �t . Lender's Name =ti Di,; .. , -a^ �"••, moi'..' -:J,',';• r � -r - PERMIT ISSUING FEE .t? '- ,f s,- 1'J S £:1'_ .f'r1 "44 Lender's''Address C.a --1 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,regu1at,ng trical wrong,.and hereby authorize w "- represe' tives of this my t . upon"the ab ve-mentioned' 'J" proper fo ms ec ,poses. }.y -P- co ' / SEE REVERSE FOR"EXPLANATORY-LANGUAGE -3/ 4S4,IJ C 11',) Signatlue of Per tee, Date - ' ' WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LJ 'I hereby'affirm that I have a certificate of consent to sett Insure, 76A663 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) PO ICy NO Company FOR APPLICANT TO FILL IN ADDRESS -Lq-7N ❑ Certified copy Is hereby furnished New Residential Bldgs.&Pools NO. EACH FEE ❑ _ $ $ miLOCALITY G7' Certified copy,is filed with the county building inspection 1 &2-Family,Sq.Ft. �r department. Multi-family Sq Ft CROSS Jq`DyfJ/V Date •Applicant Residential Swimming Pools _ ASSESSOR � �p �- MAP BOOK d PAGE !/�fX PARCEL Q CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR Outlets Rec LI ht Sw. v%7) LD COMPENSATION INSURANCE ' g • pv O FIRM NAME r• First 20 MAIL �,r� (This section ne'e'd' not be completed if the work involveii by the Total No � Additional ADDRESS/Q y� ��i} J f} e, permit is for'one hundred dollars($100)or less.) I certify that In the-performance of the work for which this permit _ CITY Is Issued, I shall not employ any persdn'in any manner so as to PLAN CHECK ^i become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT 7//�/ Total No Additional U Q /�+ J/ ADDRESS67*/ A/. Date ZI—� Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: .If,, after. aking this C tificate of CITY Tel. 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 power Apparatus&Large Appliances APPLICANT OS`7/ �,�5/ provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRES$9c,1 fITL .- 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 Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. } Over 50 t0 100 InLICENSE OR cl "� `' REG NUMBER j Class. � O x }��8B 'Over 100 DISTRICT NO PROCESSED BY License Number ✓ 1 1/ Llc Class �t U Services,Swbd,MCC&Panelboards �.!/� cc Contractor Date �—� 0-399 Amp Under 600 V _ FATE O ❑ I am exempt under Sec 400-1000 Amp Under 600 V —210 - VALIDATION W Over 1000 Amp 'or Over 600 V FINAL-' B.&P.C.for this'reason BRANCH CIRCUIT FEES BY Date. 15A,or 20A,•12DV,Lighting or Recept. z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits •i ❑ 41 Or More Branch Circuits Exemptlor for Reg.'Maint.Elect 15A,20A,208V To 277V Lighting Br.Circuits 4 a SINGLE FAMILY Temp*Power Pole&Appurtenances — -� HOME OWNER-BUILDER DECLARATION 1�'U 1 -1_'e��,' 1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Bunch Circuit a TT for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 1 ITE E 'S Code) _ ❑ Misc.Conduits&Conductors O l t AL _`2 m 8 I,as owner of the property, will do the work and the structure is not Intended or offered for sale (Section 7044;Business Other(See Complete Fee Schedule) CHECK �.4 5 and Professions Code) P(HINGEI f�1 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) 0000-[001 6,122/92" 'Civ.C) PLAN CHECKING FEE 0`f 1 1 A Ono_ Lender's Name - PERMIT ISSUING FEE Lender's Address 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 Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Str`v�,M-MIRE OF PERMIT TEE DATE '