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Home My Public Portal About6026 CAMELLIA AVE_Electrical__ ,WORKER'COMPENSATION DECLARATION 20-0019 DPW 3ie7 O �}�ere6y.affirm that I have a certificate of consent to .elf 7°^.663 APPLICATION FOR ELECTRICAL PERMIT a-8060 Insure,.or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ora certified copy thereof (Sec. 3800, Lab. C-) Pq j No 4Z a�Company S/�(F FV-110 POR APPLICANT TO FLL IN Mpg LM Certified co Is here furnished. EACH NO FEE ADDRESS 7,74 O� PY by New Residential Bldgs. 8 P�oo�s 0 Certified copy Is filed with the county building Inspec- 1 8 2-Family, Sq. Ft._ZlfSL1 $ — $ LOCALITY tlon department. I/' Mplti-family Sq. Ft. NEAREST Date Applicant A F � � • Resldentlol Swimming Pools Nom' r -FIRM NAME r M CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Llght Sw._ COMPENSATION INSURANCE ADDRESS First(This section r>Md not be completed H the work I Add ti the permit Is for one hundred dollars (=100)or I Total No. Additional 20 CITY PLAN CPIECK I certify that In the performance of the work which this APPLICANlf permit Is Issued, I shall not employ any n any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Work mpensatlon Laws. Additional Total No. CITY Tel. No. Date Total ret Flxed Appliances Not Over 1 HP p T NOTICE TOAPPLI T after making this Certificate of APRKATION Exemption sh d become subject to the Workers' Range— Heater—D.W. Com on provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS w comply with such provisions or this permit shall be T mad revoked. op — FAU —W.H. — Clly 8 Tel. No Hood — Fan —Other— LICENSED CONTRACTQRS DECLARATION Dlsp. _. Room Air Cond. — USE OR I hereby afflrm that I am licensed under provisions of Chapter 9 UMBER S/40 Class.7 ld (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. BY >_ and Professions Code,and my license Is In full force and effect. IL Size 8 Type HP, KW, KVA, or KVAR i 0 License Number�� -70.4 / 7-1.1c. C4assG—� 0 J Up to 1 Incl. FINAL Contractor- c'Nl4�C/a✓�� }e 1 Over 1 to 10 Incl. DAA 4. Z j/ VALIDATION 0 Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. By U Over 100 LLJ B.BP.C, for this reason Date: d z Services, Swbd., MCC 8 Panelboards Z 0-200 Amp. Under 600 V — Slgnature 201 - 1000 Amp. Under 600 V Exemption for Req. Malnt. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION I hereby afflrm that I am exempt from the Contracto ' License Sign with One Branch Circuit +XT T Law for the following reason (Section slness and Additional Sign Branch Circuits . 1` Professlons Code): . 56 ❑ I, as owner party, will do the work and the Misc. Conduits 8 Conductors I ITEM, struct eu not Intended or offered for sale(Section 7044, Other (See Complete Fee Scheduled ' Ti►TIAL 187 - 56 and Professions Code). t � i 1J�.0 CONSTRUCTION LENDING AGE I hereby affirm that there Is a conztru ending agency for the performance of the work f Ich this permit Is Issued PERMIT FEE (Sub-Total) (Sec. 3097, Clv. C.). LPLAN CHECKING FTE 031—I) 1 2/26/K, ender's e PERMIT ISSUING FEE `�� }}� ! { '•r i er's Address I certify that I have read this application and state that the TOTAL FEE above Information Is correct. I agree to comply with all Caunty ordinances and State laws regulating Electrical wiring, and hereby authorize representatly of this County to enter upon the abov n ctlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 2 _ ' ` Igna of Perrr�ltteeZ Date �s PON WORKERS' cI have cerci cafe of TION 7900 qDPW�� APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self ' Insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) - Policy No 22 D Company 1ST{TSS ��hJb I'O!APPLJUM TO 19LL IN JOB ADDREW ❑Certified copy Is gambry furnished. New Residential Bldgs. 8 p'0012 EACI-I NO. FEE ❑Certified copy Is filed with the county bullding Inspec- 18 2-Famlly, Sq. Ft. $ — ; LOCALITY T�/ti-Y lT tion department. Multi-family Sq. Ft. NEAREST � CROSS ST. Date 3 Applicant / ,U ' /�✓ Residential Swimming Pools OWN�R OR NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rer Light Sw._ MAdL COMPENSATION INSURANCE First 20 ADDRESS :2-C7 V11-11 (This section need not be completed tf the work Involved by Total No. Additional CITY (�,�/ Tel. No. the permit Is for ono hundred dollars (=100)or less.) 1 certify that In the performance of the work fqr which this PLAN E CK permit Is Issued, I shall not employ any ny manner Lighting Fixtures First 20 ADDRESS to as to become subject to the Worke mpensation Laws. Addltioral Total No. CITY Tel. No. Date plicant Fixed Appliances Not Over 1 HP PERWT NOTICE TO APPLI if, after making this Certificate 0f APPU} TION �A/G Exemption, u ould become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit .hall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY �T Tel. No. l�Lp —j S LICENSED CONTRACTORS DECLARATION Dlap. — Room Air Coed. — �N��R Claw. j5— I hereby affirm that I am licensed under provlslons of Chapter 9 (commencing with Section 7000)of Division 3 of the Business power Apparatus&Large Appliances DISTRICT NO. SSED BY and Professions Code,and my license Is In full force and effect. Size B,Type HP, KW, KVA, or KVAR CLO Ucense Number :t/0 14 7;Z_Lic. Class G Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE VALIDATION Er Contractor C � � J.7--y- Over 10 to 50 Incl. FINAL U ❑ I am exempt under Sec.^ Over 50 to 100 Inc. BY LLI B.BP.C. for this reason Over 100 tl Z Date: Services, Swbd., MCC& Panelboards , Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V F] Exemption 1000 Amp. 0r Over 600 V Exemption for Reg. Malnt,. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contra s License Sign with One Branch Circuit Additional Sign Branch Circuits cc Law for the following reason (Section 7031. u;lness and g r rr Professions Code): 3307 -1 •_L 1 ❑ I, as owner of the pr rty, do the work and the Misc. Conduits 8 Conductors 1 ITERS structure Is not Into o red for sale(Section 7044, Other (See Complete Fee Scheduled , TfITF� r{ cr Business and Prof Ions Code), CTION LENDING AGEiJCY CHOi �1•�! 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, Ov. C.). PLAN CHECKING FEE1[CI-[K1Q 1 ��11I Lender's Name PERMIT ISSUING FEE �7 i Lender's Address TOTAL FEE 180 1 AM O:y2 I certify that I have read this application and state 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 RFVmm FORV(PLANATORY LANGUAGE �s Signat a rmlttee Dbte