The URL can be used to link to this page

Home My Public Portal About9331 BROADWAY_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 6-663 -APPLICATION FOR ELECTRICAL PERMIT ll I herebOaffirm that I have a certificate of consent to self insure, or, a certificate of Worker'a Compensation Insurance, or a certified .COUNTY OF ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy there6f.(Sec_3800 Lab..C.) • -P olicy No.NCe^tifietl capyis hereby famished. FOR APPLICANT TO FILL IN EACH FEE 308 3/6, / ADDRESS New Residential Bldgs.&Pools _ $ $ LOCALITY ❑ Certified co is filed with the count buildin inspection 1&2-Family,Sq. Ft: PY county'building P ! s department. Mulii-family Sq.RNEAREST. Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK - PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' l OWNER DR 'J � l� COMPENSATION INSURANCE• Outlets:Rec: Ugh FirstSw. �d O' "56FIRM NAME Y' (This section need not be completed it the work involved by the Total No. 1:U. Additional ADDRESS } r o �^ permit Is for hundred dol la rs'(S100)or less.) •a"d �J G: I cartily that in the performance of:the work for which'this permit CITY G1� Tel.NS' _ 3 i5 issued'I Shall net employ any person in 2ny'manner so as to PLAN CHECK c^ become-subject to the.Workers' Compensation Laws, Lighting Fixtures First 20 APPLICANT c Total No. Additional 1 ADDRESS Date Applicant RESIDENT APPLIANCES NOT OVER,3 HP /�' NOTICE TOAPPLICANT: 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 LaborACode, you must forthwith comply with such PERMIT 4 provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances A'PucANTc/ LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9Over 3 to 10 Ind.(commencing with Section 7000) of.Division 3„of the Business and CITY Tal.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Ind. } Over 50 to 100 Incl. FEGNNU BER SE OR Class. CL Over 100 DISTRICT NO. P SSED RV O License Number Lia Class p U Services,-Swbd.,MCC&Panelboards Contractor Date 0-399 Amp,Under 600 W FDAF— INEL - ❑ I am exempt under Sec. 400-1000 Amp Under 600 V - �..Z�.� VALIDATION W FINAL Over 1000 Amp.or Over 600 V D_ B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z Date: 15A,or 20A. 120V,.Lighting or Rarest. , - 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ _ 41 Or.More Branch Circuits L Exemption for Reg,Maint.Elect. 15A,201 208V To 2M Lighting Or.Circuits ACC.1.a SINGLE FAMILY Temp, Power Pole&Appurtenances HOMEOWNER-BUILDER DECLARATION I 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 S ITEMS Code): TOTAL _- I� Mlsa..Conduits&Conductors t 6 1 JJ 1,as owner de of,the property, will do the(S work a7044, structure '.ul - - i-{-iC.!f �+1 7�l is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) /Qe._,, and,Professions Code). (,HAINI/” _ f✓ylY 1III_i 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 (Sea 3097, PERMIT FEE - (Sub-Total) Civ. C.) ' PLAN CHECKING FEE :`�`' 4 All di1;1L7 Lender's Name PERMIT ISSUING FEE a� 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 herebyauthorize representatives of this County to enter upon the above mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DE•CLARATION 76A663CE-806 D,B, APPLICATION FOR ELECTRICAL PERMIT {� he?eby f`lirm that I have a4certifigate.of consent to self insure, CE-Bose- LJ �r a cerilkate ef'.Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES - BUILDING AND SAFETY copy th,reof (Sec.3800,Lab.C.) - -Policy No. Company FOR APPLICANT TO FILL IN.- .JOB J - Certified copy is hemb furnished EACH NO. FEE ADDRESS Y New Residential Bldgs.&Pools _ ❑' Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. '1 $• T — $ ,LOCALITY G department.. Multi-family Sq.Ft. NEAREST - CROSS ST. Residential Swimming Pools ' Date � Applicant � � - OWNER OR -1 1 FIRM NAME" z=yF E J ., CERTIFICATE OF EXEMPTION FROM WORKERS' .? �� 1 a MAIL ,( COMPENSATION INSURANCE Outlets:Re Ught First 20 S U ADDRESS /LC (This section need not be completed it the.work involved by the / permit.is for one hundred dollars ($100)or less.) - Total No. (k 7 Additional CITY Tel.No. I certify that in the performance of the work for which this permit- PLAN CHECK is issued,.I.Shall not employ.any person in.any manner so as to APPLICANT become subject to the.Workers'Compensation Laws. Lighting fixtures 'First 20 < ADDRESS ' / � ^�P _ / 7 Additional X/ x Total No. /� - CITY + . Tel.No. Date� --F— , Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT.',It, after making this -Certificate of PERMIT 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 provisions or this permit shall be deemed revoked. -Top FAU L W.H. LICENSED CONTRACTORS DECLARATIONCITY Tel.No. Hood — Fan Other_ I hereby affirm that I am,licensed under provisions of Chapter 9 ucENSE OR ' (commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air.Contl. REG.NUMBER .Class. Professions Code,and my license is in full force and effect. DISTRICT BE P BED 6v Power Apparatus& Large Appliances a, Size& Type HP,KW,KVA,or KVAR s, Q License Number Lic.Class. Up 10 1 Incl. - - FINAL V ' Contractor Date . Over 1 to 10 Incl DATE / /,-J'� VALIDATI N Over 10 to 50 Incl FINAL b ~ ❑ am exempt antler Sec. Over 50 to 100 Inc. BY B.&P.C_for this reason Over 100 U) Services,Swbd.,MCC& Panelboards D Z Date: 0-200 Amp.Under 600 V Signature •201 - 1000 Amp.Under 600 V ' Over 1000 Amp..or Over 600 V ❑ "Exemption for Reg.Main.Elect _ - 'SINGLE FAMILY Temp.Power Pole & Appurtenances HOME OWNER'BUILDER DECLARATIONSign with One Branch Circuit 2 '- I hereby affirm that I am exempt from the Contractor's License Law �p/�T y for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits - ACCT..1[ _ .. Code): .-3M7 - �� ' 01" I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors Tic is not intended or offered for sale (Section 7044, Business. .Other (See Complete Fee Schedule) ITM - D -•"" and Professions Code). i0f AL .G 8 e 00 CONSTRUCTION LENDING AGENCY MILK ® LeY.J� I hereby affirm that there is a construction lending agency for the /��A1,� W �11��11 performance of the work for which this permit is issued(Sea.3097,. .PERMIT FEE (Sub-Total) - •-- -. W1f5IriiL .1JI,t Civ. C.). - - .. PLAN CHECKING FEE _ Lender's Name �I MOD- yl 6/ 5/89 PERMIT ISSUING FEE L/ Lender's Address •' - �, 1 'AM 8:53 certify that I have read this application and state that the above TOTAL FEE eUt •�.] information is correct. I agree to comply with all County ordinances and Slate laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon-the above-mentioned - pro arty for inirmittee cases . d SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Date