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Home My Public Portal About9443 BROADWAY_Electrical__ ` • -hereby WORKERS'COMPENSATION DECLARATION - -663 10/81 APPLICATION FOR ELECTRICAL PERMIT _ ! CE I hereby affirm that I have a certificate of consent to self insure, CE-Bo6G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof (Sec.3800,Lab. C.) Policy No. Company -. FOR APPLICANT TO FILL IN JOB _ 3 3 ❑ Certified copy is hereby furnished. EACH NO. FEE -DORESS - : k . New Residential Bldgs.8 Pools • ❑ Certified copy is filed' with the• ounty buildin - 1.8 2-Famil S Ft. 'LOCALITY pectin Y. 9 $ _ $ �- /r department. Multi-family So.Ft. — NEA / CROWS',.• k,7 J j 'T' ,� ��}• �/ Residential Swimming Pools Date��--eL-r/--L Applicant• g OWNER OR �J ' - FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS'. Outlets:Ree— Light.— Sw.— MAIL ' COMPENSATION INSURANCE ,- ADDRESS (This section need not he completed If the work involved by the First 20 Total No. Additional CITY o. permit is for one hundred dollars ($100)or less.) r _ T I certify that in the performance of the-work for which this permit PLAN'C ECK is issued, I shall not employ, any person in any manner so as to - APPLICANT - -- become subject to the Workers'Compens i laws. Lighting Fixtures First 20• _ ADDRESS - - . Additional Total No ' CITY Tel.No. Date '<I Applicant - �/�y- .� NOTICE. TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT ,.Exemption,you should become subject to the Workers'Compensation APPLICANT Range_ Heater_ D.W. " 0 V provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer_ W M._ ADDRESS ' .provisions or this permiGshall be doomed revoked. ' Top _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION. CITY - Tel.No. 1 'Hood— Fan _ Other_ ' T hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR (commencing with Section 7000)of Division 3 of the Business and •Disp. — Room Air Cord. .REG.NUMBER- S 7 Professions Code,and my license is in full force and effect. ` DISTRICT NO. - PROCESSED BY ' //' Power Apparatus 8 Large Appliances r°' CJ 2 Lic..Class ��0 Size 8 Type HP,KW,KVA,or KVAR O License Number ) y y Up to 1 Incl. FINAL /� V � ��+"'r"'x""�`9ate Oma(/O/ Over 1 to 10 Incl. DATE ]-4 VALIDATION Contractor Over 10 to 50 Incl. C/ - 0 FIN- U I am exempt under Sec. Over 50 to 100 Inc. gy BAP.C.for this reason Over 100 - d N Services, Swbd.,MCC 8 Panelboards I - t� - 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.Maint.Elect. SINGLE FAMILY- Temp. Power Pole 8 Appurtenances 2 - HOME OWNER-BUILDER DECLARATION Sign withOneBranch Circuit I hereby affirm that I am exempt from the Contractor's License Law a for the following reason(Section 703 1.5,Business and Professions- Additional Sign Branch Circuits Code): ACCT.r. ,- -• ' - Misc.Conduits 8 Conductors 3307 25.50 I,as owner of the property,will do the work and the structure is not intended of offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D 1 ITEMS - - and Professions Code). - .. TOTAL 25 a -J¢¢rr�•ff V CONSTRUCTION LENDING AGENCY - - - •CHECK' - 25.50 1 hereby affirm that there is a construction lending agency for the _ G performance of the work for which this permit is issued'(Sec.3097, PERMIT.FEE --, - �. (Sub-Total) _ CHARGE-�- -.'•- •. .00 Civ.C.). - Tr 40 PLAN CHECKING FEE _ .. Lender's Name �1m1��1-�1��•I- - PERMIT_ ISSUING FEE - O, 11L1 -0901 - 6/28/89 Lender's Address I �• {� 1 A(1 9 47 I certify that I have read this application and state that the above TOTAL FEE -JJ 1 information is correct.I agree to comply with all County ordinances ^' and State laws regulating Elec :cal wiring, and hereby authorize' - represen iv s of this Co to enter on the above-mentioned proper t inspection ses. SEE REVERSE FOR EXPLANATORY LANGUAGE- C�6 X Sicjfiature of Permittee Date 1 , WORKER'S COMPENSATION DECLARATION DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ 6A663 I hereby 2flirm that I have a certificate of consent to sell insure, 76A663 or a clrtificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof IS c 0 ab. C.) Polley No. ° i a/Iy FOR APPLICANT TO FILL IN ADDRESS 7 ❑ 'Certified copy is hereby furnishad. New Residential Bldgs.&Pools NO. $ EACH $ FEE LOCALITY Certified copy is filed with the count buildi g inspection 1 8 2-Family,Sq.Ft. de�tmrr NEAREST en Multi-family Sq.F1. CROSS ST. DateIz�Applicant A Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' ..Outlets:RBC._Light Sw._ OWR OR p� COMPENSATION INSURANCE FIRM NAME G �' - Additist onal 0 MAIL f y r (This section need not be completed if the work Involved by the Total No. Atlditional ADDRESS (T L J permit Is for one hundred dollars(4100)or less.) _ I certify that intheperformance of the work for which this permit _ - CITU Tel.NJ 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 PUN CHEOK APPLICANT Total No. Additional ADDRESS Data Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE APPLICANT: after making this Certificate of CITY Tel.Na Exemption,, you should become .sublect to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with suchPERMIT 1,/G� provisions or this permit shall be deemed revoked. - Power Apparatus&Large Appliances - APPLICANT r LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS ,% I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3o the Business and Over 3 to 10 Ind. CITY hfTel.No. Professions Code, and my license is in full force and effect. Over 10 to 50 Ind. } Over 50 to 100 Incl. LICENSE ORp- pREG.NUMBER LO L7 License Number �1 ��'L� / Lic.Class C—& /, Over 100 DISTRICT No. PWSSED BY 0 A / r Services,Swbd.,MCC&Panelboards cc COntraC t(�.�/ AW/Z &&9lle L / I 0-399 Amp'Under Und600 V FINAL 0 • '— DAT❑ U VALIDATION 400-1000 Amp.Under 600 V G— / W I am exempt under Sec. Over 1000 Amp,or Over 600 V FINAL d 8.&P.C.for this reason BRANCH CIRCUIT FEES BV _ Date: 15A,or 20A, 120V,Lighting or Recept. Z Signature 1 To 10 Branch Circuits 11 To 40 Branch Circuits 041 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,206V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenancesx HOME OWNERBUILDERDECLARATION 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 .-D-, Code): r. ' ' 1 iT_tt_ ❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductorsn 6.0 rc is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I0TAL 6 ® -- and Professions Code). D j+l I�`,�, �,7°;. CONSTRUCTION LENDING AGENCY `.[HIA�.�r I hereby affirm that there is a construction lending agency for the - UE performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) PLAN CHECKING FEE - I1Q1]Li—i iJl]j. '?.^_10?4 Lender's Name G 671? y. _AM ?W PERMIT ISSUING FEE i Lender's Address fo I certify that I have read this application and under penalty of purlury state TOTAL FEE that the above information is correct. I agree to comply with all County - ordinances and Stale laws regulating Electrical wiring,and hereby authorize represent rives of this Counryto enter u The above-mentioned property for ins ti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE NATURE OF pE .-- / WORKER'S haveCOMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ 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 FUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof,(Sec.3800 Lab. C.) . Policy No. Company FOR APPLICANT TO FILL IN JOB OBRESS ❑ Certified copy is hereby furnished. r New Residential Bldgs.&Pools NO. EACH FEE r ❑. 'Certified co 1 &2-Family,Sq.Ft. — $ $ LOCALITY copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. CRo55 RT. i/E r Date '- Applicant Residential Swimming Pools ASSESSOR •��( MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw J—ection OWN 1V1 NAME r COMPENSATION INSURANCE QO �/ 0 (This sneed not be completed the work Involved by the MAIL Total No.! First 20 Additional ADDRESS permit is for one hundred dollars(51000)or less:) I certify that in the performance of the work for which this permit CITY, ,� x Tet.No. is issued, I shall not employ any person in any manner 0 as to PLAN CHECK become subject to the Workers'Compensation aws. Lighting Fixtures First 20 APPLICANT tal No. Additional. ADDRESS Data //- 3. 9� Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. `�' NOTICE TO APPLICANT: If, after ma ing this Certificate of CITY Tel.No. Exemption,youshould become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such 'ERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT ' I 'LICENSED CONTRACTORS DECLARATION o •iSize&Type HP,KW,KVA,Or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 O1 i 2 . Over 3 to 10 Incl. •1� J1 5-O 419 (commencing with Section 7000) of Division 3 of the Business and CITY ,t; Tel. Professions Code,and my license is in full force and effect. Over 10 to 501nct. A. } Over 5010 100 Incl. LICENSE OR REG.NUMBER Class' d Q /� / Over 100 DISTRICT NO. PROC,.. E �^ O License Number J Lic.Class L –/� R U AS,,ervices,Swbd.,MCC&Panelboartls S/D!/ Cc Contractor Date Z/ Mr .3 94 CI11- 0-399 Amp.Under 600 V C31 0,1, FINAL O GATE 400-1000 Amp.Under 600 V ❑ -r I am exempt antler Sec. `�? VALIDATION V Over 1000 Amp.or Over 600 V W B.&P.C.for this reason FINAL a- BRANCH CIRCUIT FEES Date: 15A,or 20A, 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature '11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Mart.Elect. 15A,20A,208V To 277V Lighting BE Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances `I r HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from,the Contract0 rs License Law Sign with One Branch Circuit E71_;,.T,s for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits :'r7 jil.�tfi Code): ,a !j Fl 0t II, as owner of the property, will do the work and the structure Misc.Conduits&Conductors 1 1 1IC is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schetlule)_ -,I_I i AtttiL 270 - 00 and Professions Code). {, CONSTRUCTION LENDING AGENCY -:PECK C K 271301!'0 I hereby affirm that there is a construction lending agency for the CLANG_ performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) O Civ. C.) PLAN CHECKING FEE Lender's Name 00130-0131-1 PERMIT ISSUING FEE vcCj u o '- Lender's Address -1t 1 P 11.E e 1G I certify that I have read this application and under penalty of perjury state TOTAL FEE that the above information is correct. I agree to comply with all County - ordinances and State laws regulating EI tricot wiring,and hereby authorize representatives of thi Ounly to ante upon the above-mentioned property Zn'on ppu es. SEE REVERSE FOR EXPLANATORY LANGUAGE sIVIPURE OF PERMITTEE PATE