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Home My Public Portal About6028 BURTON AVE_Electrical__ .WORKERS'COMPENSATION DECLARATIGN : S ;76A8e063 66 10/B,i „I.her6Gy affirm that I have a certificate of corsensta 'S'elf, ., APPLICATION pmmLICpTIOaFOR L L tCTwA L PERMIT insure, or a certificate of Workers' Compensation Insurance, COUNTY OF-LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, lab. C. F Policy No. Company FOR APPLICANT TO FILL IN - - JOB / y) �� Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS 6 TJ u ' Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. E — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant - OWNER OR l e�goQ, Q FIRM NAME L CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re--Light U Sw. 'MAIL /�yL�r COMPENSATION INSURANCE �L ADDRESS (" M9 (the permit is For one hundred dollars ($100)or less.) This section need not he completed if the work involved b � r� First 20 P Y Total No.�L Additional ITY Tel. No. 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 �/'7 [� . Additional !/F//L� 'L' c,.v V7YfA'✓ CITY F 1 Dale Applicant Total NoTel. No.Fixed Appliances Not Over 1 HP PERMI /� NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT 11 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 r Gr with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITY Tel. No. L� LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ LICENSE OR i I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER A0 Class.G/O (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. y -5-,0 PROCES D BY Y and Professions Code,and m license is in full force and effect. r /, (/ [/ � Size 8 Type HP, KW, KVA, or KVAR' -1 ,0 J 0 License Number /Dd 1(7 Z Lic Class C�Q -y/7 Up to I Incl. FINAL p- W ?12iAE F C2� -/1 9O Over 1 to 10 1nc1. DATE �d �� p�lJ VALIDATION 0 Contractor / Dote I Over 10 to 50 Ind: O FINAL {~j El I am exempt under Sec. Over 50 to 100 Inc. BY �j�,f/s•� � B.BP.C. for this reason Over 100 Date: Services, Swbd., MCC 8 Ponelboards 0 -200 Amp, Under 600 V Signature 201 - 1000 Amp. Under 600 V ' ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Mainz. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances zT2 6 5 6 A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License .Sign Branch Circuits # o o; 'o oa 2 Law for the following reason (Section 7031.5, Business and Professions Code): Z.e O O I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors x structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D o o'o 4Q,O O v 7044, Business and Professions Code). (i 7'1 1 -84 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 PERMIT FEE (Sub-Total) s (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name O PERMIT ISSUING FEE (� Lender's Address I certify that I have read this application and state ;hat the TOTAL FEE q 0 above information is correct. I agree to comply with all County ordinances and State lows regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property fa inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permi ee Date WORKERS'COMPENSATION DECLARATION 76A663 IQ,/81 4)f APPLICATION PP IC p TION FOR ELECTRICAL ECTRIC p B PERMIT I hereby affirm that I have o certificate of consent tm self i . CE;8o6G IF�Ir IL `LYV 4 Iltl FOR IG IL IG`�a II Y'( 'bd"1lL Ir LS II'(tlN9 II . insure, or a certificate of Workers'Comperrsajion Insurance, COUNTY OF LOS ANGELES T, BUILDING AND SAFETY or a certifiedcopytheregfQ(Sec. 3800, Lab. Cf. r� , , ®cy Nod&Jrd, �Company Ls P• y' ,i/�S , FOR APPLICANT TO FILL IN JOB �O� ^' Certified copy is hereby furnished. EACH O.New Residential Bldgs. 8 Pools NFEE ADDRESS /V Certified copy is filed with the county building inspec- 18 2-Family, Sq. FI. $ — $ LOCALITY tion department. Multi-family Sq. Ft. — 'NEAREST CROSS Date_,rte/�r/S-/Applicont .,! /y%f`i Residential Swimming Pools OWNER TOR . FIRM NAME 7'7-' s•-�ArF CERTIFICATE OF EXEMPTION FROM WORKERS' OutMAIL lets: Rec_Light_Sw._ COMPENSATION INSURANCE � First 20 ADDRESS SH1TJ.$ (This section need not be completed it the work involved by Total No. 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'Compensation Laws. Lighting Fixtures First 20 ADDRESS ,q Total No. Additional pplicant Y�y,,� tL✓� CITY Tel. No. Fixed Appliances Not Over I HP PERMIT NOTICE TO n, APPLICANT: If, after making this Certificate of APPLICANT P Exemption, you should become subject to the Workers' Range_ Heater—D.W. � -� � � l��gLe O"/L!� Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M._ ADDRESS aS� g �•]Lf�r with comply with such provisions or this permit shall be Top _ FAU —W.H. — .s7 deemed revoked. Hood _ Fan _ Other_ CITYi5iTel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER &C>/3 RC1 ss.C-/(D (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCESSED'BY and Professions Code,and my license is in full force and effect. r/ IL Size 8 Type HP, KW, KVA, or KVAR' S '0 G License Number >jlc/Jz Lic. Class C� Q Up to I Incl. '� Qr 'v V p FINAL /' 99 Contractor_7_it7Y/P.Z,�" F Date- [p^e2I'-O� Over 1 to IO Incl DATE - � !- VALIDATION Q ❑ Over 10 ro 50 Incl. FINAL' ((ll 7 F I am exempt under Sec. Over 50 to 100 Inc. BYc IM (` Z 1 B.BP.C. for this reason Over 100 N Services, Swbd., MCC 8 Panelboards D r/ /r �L ? Date: 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Mainz. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Si n with One Branch Circuit Rl I hereby affirm that I am exempt from the Contractor's License g #Additional Sign Branch Circuits o• {y(,�? Law for the following reason (Section 7031.5, Business and t " 50 5 0 Professions Code): ?la ° 7 ElI, as owner of the property, will do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 7044, Business and Professions Code). g , 1 -84 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE o ro Lender's Address �!1 _rte ° ° A4 I certify that I have read this application and state that the TOTAL FEE iv • °- °CJ above information is correct. I agree to comply with all County L' -42,- P so, ordinances and State laws regulating Electrical wiring, andp .C3 °, - hereby authorize representatives of this County to enter upon �� J rQ .,4-- hereby ®' Cn ^P the above-mentioned property for in pec lion purposes. Yom) O N7. SEE REVERSE FOR EXPLANATORY LANGUAGE CH ignoture of Permiltee Date