The URL can be used to link to this page

Home My Public Portal About5453 CLOVERLY AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) Op��C�AYMN FOR [ELIEC��1 IDICQL [PER w�i 'r 76-663 p p p O o I hereby affirm 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.) PolicyNo. Com an FOR APPLICANT TO FILL IN JOB r -y ❑ p y ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools M0.1ACH FEE / o ❑ $ LOCALITYCertified co Is filed with the count buildin Ins ection 1 &2-Family,Sq.Ft.PY y 9 P NEAREST department. Multi-family Sq.Ft. CROSS ST. f' Date Applicant Residential Swimming Pools ASSESSOR �y MAP BOOK ��O PAGE �/ PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FlRM NAME COMPENSATION INSURANCE (This section need not be completed if the work involved by the First 20 MAIL permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS5 C ddd I certify that in the performance of the work for which this permit CITY llg r Tel.N . _q. ` is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT �1� LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 Incl. LICENSE OR Cl REG.NUClass. License Number Lia Class O Over 100 DISTRICT NO. PRO SSED BY Services,Swbd.,MCC&Panelboards �� T Contractor Date 0-399 Amp.Under 600 V S � � FINAL DATE ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V �. �' W Over 1000 Amp.or Over 600 V FINAL VALIDATION B.&P.C.for this reason BRANCH CIRCUIT FEES BY Q_ Date: 15A,or 20A, 120V,Lighting or Recept. 1 To 10 Branch Circuits 3 Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuit$ Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.CircuitsFe SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION '' I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits i ode I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors s not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) O and Professions Code). 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 (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address ,y ` I certify that I have read this application and under penalty of purjury state TOTAL FEE c g 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 u the above-mentioned property for n purposes. n too SEE REVERSE FOR EXPLANATORY LANGUAGE SI URE OF PERMITT E -- DAVt i� WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT 76A66 1 hereby affirm that I have a certificate of consent to self insure, 76A663 or a'ce'rtificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy;hereof(Sec. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE $ _ $ LOCALITY F-1Certifiedcopy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR 16 MAP BOOK v� PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. `' /fGORM NAME ! - -� °� WNER OR COMPENSATION INSURANCE First 20 ' (This section need not be completed if the work involved by the ZS `— AIL permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS I certify that in the performance of the work for which this permit CITY'�i AJ1L& 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 Fixtures n First 20 APPLICANT Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel No Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH --APPLICANT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH CLO (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. U Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Power Apparatus&Large Appliances REG.NUMBER Class. Q License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY Up to 3 Incl. Over 3 to 10 Incl. FINAL IZ Contractor Date DATE (n ❑ Over 10 to 50 Incl. Z I am exempt under Sec. Over 50 to 100 Incl. L� VALIDATION Over 100 FINAL B.&P.C.for this reason BY Services,Swbd.,MCC&Panelboards Date: 0-200 Amp.Under 600 V Signature 201 -1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 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) ' and Professions Code). 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 (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address �f I certify that I have read this application and state that the above TOTAL FEE a nformatio is correct. I agree to comply with all County ordinances and Sta laws regulating Electrical wiring, and hereby authorize represe tf this County to enter upon the above-mentioned proper or Ins coon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGN URE OF APPLICANT OR AGENT DAT