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Home My Public Portal About5414 CLOVERLY AVE_Electrical__ WORKER S COMPENSATION DECLARATION 200019 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT 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 PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 3600 Lab C) ' Policy No Company FOR APPLICANT TO FILL IN JOB NO I EACH FEE �I�ADDRESS 6411'1 Q R Certified copy Is hereby furnished New Residential Bldgs &Pools LOCALITY El 1 &2 Family Sq Ft _ $ $ Certified copy is filed with the county budding Inspection NEAREST department Multifamily Scl Ft CROSS ST DateApplicant Residential Swimming Pools ASSESSOR ' MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Rec _Light Sw OWNFIRM NAME i 'COMPENSATION INSURANCE First 20 MAIL or (This section need not be completed If the work involved by the ADDRESS permit is for one hundred dollars($100)or less) Total No Additional I certify that in the performance of the work for which this permit CITY Tel No is Issued I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers Compensation Laws Lighting FixtLres First 20 APPLICANT ' Total No Additional ADDRESS Date $' 3 Apphcant�.�Cv �"t� cG RESIDENTIAL APPLIANCES NOT OVER 3 HP NOVICE TOS APPLICANT If after making this Certificate of CITY Tel No Exemption,you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP provisions,of the Labor Code you must forthwith comply with such APPLICANT provisions or this permit shall be deemed revoked " Power Apparatus&Large Appliances �✓ �+ A c LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS 1-712I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl ; M (commencing with Section 7000) of Division 3 of the Business and Over 10 to 50 Incl j CITM")0,JA",a Q1"] Tel N / ?f_T�1 Professions Code and my license is in full force and effect LICENSE OR } Q Q Over 50 to 100 Ind REG NUMBERS 4 O ClassG iC d r6 / 6-0 a LIc Class C�0 Over 100 DISTRICT NO P OC ED BY O License Number � p �� Services,Sw/fid C Pa bo s / / �6 G�G O ,r�$--Q3 0' 399 Am Under �(O FINAL Contractor � :4k1 t��Date p DATE F- ❑ - 400 1000 Amp Under 600 V �2-� U I am exempt under Sec VALIDATION LU Over 1000 Amp or Over 600 V FINAL d B&P C for this reason - BRANCH CIRCUIT FEES BY co Date S'a .(� 15A,or 20A 120V Lighting or Recept Z e- 1 To 10 Branch Circuits Signature l'"L^ 11 To 40 Branch Circuits - ❑� 41 Or More Branch Circuits Exemption for Reg Maint Elect 15A 20A 208V To 277V Lighting Br Circuits 3 r SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ITEMS? I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits TOTAL- 61 - 65 Code) tr HECK � t 4°Ec` I, as owner of the property will do the work and the structure Misc Conduits&Conductors f{tGF El is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) CHANGE o 00 and Professions Code) - CONSTRUCTION LENDING AGENCY 0r!ryry tIl i oo 1 hereby affirm that there is a construction lending agency for the Vd -LI performance of the work for which this permit is Issued (Sec 3097 PERMIT FEE (Sub Total) 1p 013130 f AM va)1i1 Civ C) J tot PLAN CHECKING FEE Lender s Name /7 PERMIT ISSUING FEE �C Lender's Address I certify that I have read this application and under penalty of pupury state TOTAL FEE Com/ !L' 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 -�51GNATURE OF PER DATE WORKER S COMPENSATION DECLARATION 20 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT 76A663 I hereby affirm that I have a certificate of consent to self Insure 76A663 or a certificate of Worker s Compensatlonl nsurance or a c6rtified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof.(Sec(338`800 Lab C) " POMC r _V_� Company ob FOR APPLICANT TO FILL IN JOB 4 ADDRESS U Certified copy Is hereby furnished New Residential Bldgs &Pools NO 4ACH FEE LOCALITY ❑ 1&2 Family Sq Ft — $ $ Certified copy Is filed with the county building Inspection NEAREST V d pa ment _��[) Multi family Sq Ft CROSS ST Date ` I� Applicant -0(� ` Residential Swimming Pools ASSESSOR MAP PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Rec —Light�Sw FFIIRM NAME i►[�� WNER OR COMPENSATION INSURANCE /y _ First 20 MAIL { /�/ 6VCm� _ (This section need not be completed 0 the work involved by the Total No Additional ADDRESS l l�h 16'Cic i permit is for one hundred dollars($100)or less) ._�, I certify that In the performance of the work for which this permit CITY 1 Tel No '7? is issuedI shall not employ any person In any manner so as to PLAN CHECK become s blect to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT Total No Additional ADDRESS Date Applicant "0 RESIDENTIAL APPLIANCES N OVER 3 HP n NOTICE TO APPLICANT If, after making this Certificate of CITY , Tel No Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP PER �)� IT provisions of the Labor Code you must forthwith comply with such APPLICANT - `{`�L) provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances " ` LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS V.�+J S rn I hereby affirm that I am licensed under provisions of ChaprStoiTln Chapter 9 ( O ,fcl (commencing with Section 7000) of Division 3 of the Business andCITY Tel No J Professions Code and my license is in full force and effect f Over 10 to 50 Incl LICENSEClass _ Over 50 t0 100 Incl REG NUMBER a^ 7/� ~i Over 100 DISTRICT NO ESSED BY 0 License Number Lic Class (-- �n O � t` �f I= ' UQ Services Swbd MCC&Panelboards � Contractor ' Date 0 399 Amp Under 600 V FINAL -DATE 0 ElVALIDATION 400 1000 Amp Under GOO V I_I am exempt under Sec 0 Over 1000 Amp or Over 600 V FINAL W B&P C for this reason BRANCH CIRCUIT FEES BY (d 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 Maint Elect 15A 20A 208V To 277V Lighting Br Circuits 2' SINGLE FAMILY Temp Power Pole&Appurtenances r HOME OWNER BUILDER DECLARATION ACCTeJ' I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Circuit � ti t for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits _ , 303 61.7 5 Code) I J - I ITEMS❑ 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) ® TATAL 61 -75 and Professions Code CHECK 61e, CONSTRUCTION LENDING AGENCY V HANVE eCIO I 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) Civ C) PLAN CHECKING FEE lU-1�DD1 7/15/96 Lender s Name 7437 1 Arlt j a 7 1 PERMIT ISSUING FEE Lender s Address I certify that I have read this application and under penalty of purlury state TOTAL FEE �, 5 that the above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring and hereby authorize reAr sen Ives of this County to enter upon the above ention property f pf�1 ti n ur k SEE REVERSE FOR EXPLANATORY LANGUAGE SI R OF VYITTEE DA