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Home My Public Portal About6030 CAMELLIA AVE_Electrical__ woRIRS' COMPENSATION DECLARATION �3 � APPLICATION FOR ELECTRICAL PERMIT O J,�oreby*+fflrm that I have a certlflcate of consent to self a4Xp60 Insurer or a cerfificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) VNo 3 Company �S/LT r� l1V p FOR ArPLICJ►HT TO RLL W JOB �v Certified copy Is ereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS WW❑Certified copy Is filed with the county building Inspec- 1 &2-Family, Sq. Ft..�L $ _ ; LOCALITY tion department. Multi-family Sq. Ft. NEAREST 411 Residential Swimming Pools CROSS ST. Date Applicant ` 0' � - g OWNIER ` RM NAME s.! CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re* Ught Sw._ MAIL COMPENSATION INSURANCE ADDRESS First 20 (This section rseed not be completed N the work Imrohred by Total No. Additional CITY Te. No. !y f_ the permit ts for one hundred dollars ($100)or less.) PLAN OiECY I certify that In the performance of the work for ch this APPL}C�T permit Is Issued, I shall not employ any�erso ny manner UghtIN Fixtures - First 20 ADDRESS to as to become subject to the Worker pensation Laws. Additional Total No. CIN Tel. No. Date Appll Fixed Appliances Not Over 1 HP ! PERMff NOTICE TO A after making this Certificate of Ran Heater—D.W. — TIbN ' Exemptlo u should become sublett to the Workers' RangLl 1Aj!q e— tion provisions of the Labor Code; you must forth- Oven — Dryer —W.M.— 1 ADDRESS comply.with such provisions or this permit shall be Top FAU —W.H. CITY S, Tel. No. f deemed revoked. Hood Fan —Other— LICENSED CONTRACTORS DECLARATJON L]CENSE OR 41 I hereby affirm that I am licensed under provisions of Chapter 9 DI}p. Room Air Cond. — REG, UMBER IQ Class. -46 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. BY d and Professions Code,and my license Is In full force and effect. r �, Size &Type HP, KW, KVA, or KVAR O License Number �1R 7 LIc. Classes Up to 1 Incl. FINAL U Over 1 to 10 incl. DATE -+Z VALIDATION Contractor Cy1�C#6W�E note Z Over 10 to 50 Incl. FINAL ~ ❑ I am exempt under Set. T— Over 50 to 100 Inc. gy U W B.&P.C. for this reason Over 100 IL Servlcgs, Swbd., MGC&Panelboards , z Date: Z 0-2Q0 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Rep. Malnt. Elect. Over 1000 Amp. or Over 600 V � SINGLE FAMILY Temp. Power Pole&Appurtenances ` HOME OWNER BUILDER TIC�I I hereby affirm that I a p om the Contractors•Llcense Sign with One Branch Circuit W.CT.T Law for the fall reason (Section 7031.5, Business and additional Sign Branch Circuits i337.a Professions e): ITEMS , 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 (�Complete Fee Schedule. , TOTAL 137 -c6 Business and Professions Code). CONSTRUCTION LENDING CY CII_ i 1��. � 1 hereby affirm that there I uction lending agency for the performance ork for which this permit Is Issued PERMIT FEE (Sub-Total) (Sec. 3047, L qrs Name PLAN CHECKING f� C��fU-C 11 _)/26/T2'� PERMIT ISSUING FEE Lender's Address I certify that t have read this appllcotlon and state that the TOTAL FEE above Information Is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby author) a represent es of th unry to enter upon the a Ion for Ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Ignwture mlttee Date WORKERS'COMPENSATION cafe of 19 �� APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self '��g�yp Insure, or a certificate of Worker' Compensatlon Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy,thereof (Sec. 3800, Lab. C.) - Policy No 1-114oil Company 1ST<{T¢ X01y1> FOR APPuCANT TO RLL IN JOB ❑Certtfled copy Is l4efebry furnished. New Residential Bldgs. 6 Pools EACH NO. FEE ADDRESS 40 ❑Certified copy Is filed wlth'the county building Inspec- 1 & 2-Family, Sq. Ft. ; _ $ LOCALITY T(7M i T tion department. Multi-family Sq. Ft. NEAREST L Residential Swimming Pools CROSS ST. Date '3 Appllcan"��- / 'u ' l�C - RM NAME / CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets: Rem LJght Sw._ ADDRESSVIA A A4 65 (This section need not be completed if the work Imrohred by First ti CITY Tel. No. _ the permit Is for one hundred dollars(:100)or leu.) Total No. Additional O !�� CAECK I certify that In the performance of the work fqr which this APPUCANT / permit Is issued, I shall not t to employ any any manner Lighting Fixtures First 20 ADDRESS so as to become subjecthe Work mpensatlon Lows. Additional Total No. CITY Tel. No. Date Ilcant Fixed Appllances Not Over 1 HP PH2Mff NOTICE TOAPPLI tf, after making this Certificate of APPLICATION /�✓G Exemption, u ould become subject to the Workers' Ram— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS z T If with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. Hood Fan —Other— CIN Tel. No. D —3 >— LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. Room Air Cord. — REG, NUMBER Class. 1 hereby a fIrm that I am llcensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business power Apparatus& Large Appliances DISTRICT NO. BY a and Professions Code,and my license Is In full force and effect. Size&,Type HP, KW, KVA, or KVAR OF O Ucense Number :t/047_—Lic.Class up to 1 rncl. FINAL cc C Contractor �� ' 4Z Over 1 to 10 Incl. DATE 2 )` VAUDAT*N 0 Over 10 to 50 Incl. FINAL o� l U ❑ I am exempt under Set. Over 50 to 100 Inc. BY LLI B.&P.C. for this reason Over 100 a Z Services, Swbd., MCC & Ponelboards , Date: z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for ROver 1000 Amp. or Over 600 V eg. Malnt. Elea. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION ti Temp. Power Pole 8 Appurtenances I hereby affirm that I am exempt from the Contr s License Sign with One Branch Circuit T OON� Law for the following reason (Section 7031. upness and Addltlonal Sign Branch Orcults T�1 rc Professlons Code): 7 59.5 ❑ J, as owner of the pr do the work and the Misc. Coodults&Conductors 1 ITEM _ structure Is not Inte ed 0 ed for sale(Section 7044, Other (See Complete Fee Schedule).._ Pool TOTAL �r Business and Prof Ior�s Code), _ CT LENDING AGENCY CHECK 59-5! 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, Cly. C_). PLAN CHECKING FEE Lenders Name jiJ 3j/1��` Lender's Address PERMIT ISSUING FEE TOTAL FEE � 21901 AM ua:42 1 certify that I have road 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 REVERSE FOR EXPLANATORY LANGUAGE ms Signa" a ermittee Dh to