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HomeMy Public PortalAbout9614 BROADWAY_Electrical__ WORKER COMPENSATION DECLARATION 720 0019 6A663 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT Ll I hereby affirmhave 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.) FOR APPLICANT TO FILL IN JB ); t, Policy No. Company gOpDRE55 4- �'V ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY Certified co is filed with the count building inspection 1 8 2-Family,Sq. Ft. department. y 9 p Multi-family Sq.Ft. CROSSST. QA 'fj P Y PIE f�( $Id Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK I PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. RRM OWNENAME R OR O. jAti L� /� COMPENSATION INSURANCE IV First 20 MAIL D (This section need not be completed if the work involved by the Total No. Additional ADDREBs permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY• J f!lTel.No. ' ,171 1 is issued, I Shall not employ any person in any manner s0 as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No Additional ADDRESS Date 'Applicant RESIDENTIAL.APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY TeI.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 Power Apparatus&Large Appliances - APPLICANT �LC� LGc.��.✓ provisions or this permit shall be deemed revoked. 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 101nc1. (commencing with Section 7000) of Division 3 of the Business and CITY TeI.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Ind. } Over 50 to 100 Incl. LICENSE OR Class. REO NUMBER d Over 100 DISTRICT NO. P�Or,56BED BY 0 License Number Lie.Class �D Q T 0 Services,SIR.,MCC&P�/DeeIbOagrtls_L, O C5.- cc Contractor Date 0-393 Amp.Untl€r 600 V1 Dg7E �•7 0 ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V —X� ~ UUU VALIDATION U Over 1000 Amp.or Over 600 VNAIL a B.&P.C.for this reason BRANCH CIRCUIT FEES B1Y1 U) Date: 15A,or 20A, 120V,Lighting or Recept. Z_ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El - 41 Or More Branch Circuits ' Exemption for Reg.Maint. Elect. 15A,20A,208V To 277/Lighting Br.Circuits ��1�/ +=•tee_-: SINGLE FAMILY Temp, Power Pole&Appurtenances HOMEOWNER-BUILDER DECLARATION J, { )Ei13 1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit �1 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits TOTAL 61 - 65 Code): ❑ CHECK 61.65 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) CHANGE and Professions Code). CONSTRUCTION LENDING AGENCY 0000-000i Ar/ 2/93I 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) 90121 A .LO=;a Civ.C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE �� r Lender's Address �� TOTAL FEE W G I certify that I have read this application and under penalty of purjury state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize .-pr @ s of this Cou ty to enter upon the above-mentioned property x for inspect } ose I SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE I I DATE WORKERS' COMPENSATION DECLARATION za.Wto DPW 3,87 APPLICATION FOR ELECTRICAL PERMIT O I herA4iy afi'SC+sn that I have a certificate of consent to self Cp�C i nsv-e, or a ert,ficate of Workers Compensation Insurance, COUNTY.OF LOS ANGELES DEPT. OF PUBLIC WORKS or t�,edifiect,copy thereof (Sec. 3800, Lab. C.) PancyrNa: !C94367c7ompany Republic Indemnity FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO, FEE ADDRESS 9614 Broadway ©Certified copy is filed th c '�ipec1 a 2-Family, Sq. Ft. $ — $ LOCALITY Tem le Cittion department. - Multi-family Sq. FL — NEAREST CROSS ST. /25/ Residential Swimming Pools OWNER OR Date A is t FIRM NAME Mr. & M cs. Ronald Mine. CERTIFICATE OFE TION FROM WORKERS' Outlets: Rec—Light_Sw._ MAIL COMPE ION INSURANCE ADDRESS 9614 Broadway (This section need not be completed if the work involved by First 20 CITY Tem le Gt Tel. No.309-9111 the permit is for one hundred dollars ($100)or less.) Total No. Additional P y 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' Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over I HE PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Exemption, you "should become subject to the Workers' Range— Heater.--_D.W. — Bryant Heating & AIC, Inc Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 1350 East Las Tunas Drive with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY San Gabriel Tel. No. 286-1141 - LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER 221751 Class. C-20 (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances ! DISTRICT NO. PR ESSED BV >_ and PrCNum ns ode, and y ense is in full force and effect /(/ d d Size 8 Type HE, KW, KVA, or KVAR p w. �O O Licens 1751 L' Class C-2(� 2hp Up to 1 Incl. FINAL Contra e ' Over 1 to 10 Incl. DATE VALIDATION Cr 6/2593 0 3 O ❑ Over 10 to 50 incl. FINAL F I exempt and ea Over 50 to 100 Inc. BY CJ W B.aP.C. for this r ason Over 100 d Services, Swbd., MCC a Ponelboards it ZZ Date: 0- 200 Amp. Under 600 V — Signature 201 - IODO Amp. Under 6DO V ❑ Exempliort for Reg. Moint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION i., _ .. - I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit - - -'-- ` ATI s.),r Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits .- _. .. x..07 _ -. 4-'e DO Professions Code): - `^� `t 1:1Mi . Conduits a Conductors 1 -TT ENS sc I, as owner of the property, will o the work and the _ _ structure f not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ pop. - -- T_iTAL 43 o "S0 Business and Professions Code). IL V Lt CONSTRUCTION LENDING AGENCY X I hereby affirm that there is a construction lending agency for CHANGE the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). Lender's Name PLAN CHECKING FEE / 1}Qtjl -I1i 11'i�, bibyi'J p�a'�o7 PERMIT ISSUING FEE - 1.141' j Al'llll,?c Lender's Address -� I certify that I have read this application and state that the I TOTAL FEE above ' ormo' n is correct. e to comply with all County ,.. Ordin Hees and Slat reg ting Electrical wng, and here y outhori rativ of this County to enter upon In ve- t' ne or insp ctiO Pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE 6/25/93 Si oture Per. Date �'