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HomeMy Public PortalAbout5836 CLOVERLY AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION. FOR ELECTRICAL PERMIT 4-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 DER.T. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL INt JOB �) Certified co s hereby furnished. NO. EACH FEE ADDRESS CLD L/��.CA aV PY Y New Residential Bldgs.&Pools ❑ _ $ $ LOCALITY'T w r Certified co is filed with the count building inspection 1&2-Family,Sq.Ft. PY Y 9 P NEAREST ✓ department. Multi-family Sq. Ft. CROSS ST. L(17 1 U? Q✓) Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS'- Outlets:Rec. Light Sw. OWNER OR r / COMPENSATION INSURANCE g F � ��IRM NAME L f l C r L( .�9 (This section need not be completed First 20 MAIL permit is for one hundred dollars($100)or less.) 'the work involved by the Total No. Additional ADDRESS 7 / (�U L C o /,1 d r I certify that in the performance of the work for which this permit CITY p PCZTel.No. � is issued, I shall not employ any person in any manner so as t0 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 PERMIT of the Labor Code, you must forthwith comply with such APPLICANT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances 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. LICENSEClass. 0' Over 50 t0 100 Incl. REG.NUMBB ER 0- License Number Lic.Class �L/ Over 100 DISTRICT NO. y� P SSED BY O Services, /,Tdfg boards" �/�// ��/�� �✓� U 0-399 Amp.Under 600 V FINAL O Contractor Date DATE El 400-1000 Amp.Under 600 V I am exempt under Sec. VALIDATION V Over 1000 Amp.or Over 600 V FINALW B.&P.C.for this reason BRANCH CIRCUIT FEES BY .b!"Q Date: �7 CAI a 15A,or 20A, 120V,Lighting or Recept. T ��vrL© Z _ - 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits JT Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits A SINGLE FAMILY Temp.Power Pole&Appurtenances n _ 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 ITEMS Code): El I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors L 3 = 45 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) CHUCK and Professions Code). '_"HAKE 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) %�'� C-11 !"'— s#y Civ. C.) t _)�13! S,sI 7 3! ;" T PLAN CHECKING FEElfL -Fli_°,( Lender's Name ` y PERMIT ISSUING FEE Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE 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 fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,r I-G IGNATURE OF PERMITTEE U D E WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-9i) 76A663 APPLICATION FOR ELECTRICAL PERMIT 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.) Policy No. Company FOR APPLICANT TO FILL IN ADJOB DRE9� Elj'i -�f-�e Certified copy is hereby furnished. New Residential Bldgs.&Pools NO, EACH FEE $ $ LOCALITY Certified copy 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 PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw, ORM NAME COMPENSATION INSURANCE First 20 MAIL (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 t0 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 LICENSED CONTRACTORS DECLARATION Size&Type HP,KW, KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl. CITY Tei.No. d Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 Incl. LICENSE 0 REG.NUMBB ER Class. V License Number Lic.Class Over 100 DISTRICT NO. PROCESSED BY Ill J Services,Swbd., MCC&Panelboards LL Contractor Date 0-399 Amp. Under 600 V FINAL DDATE >_ EJ 400- 1000 Amp. Under 600 V Q I am exempt under Sec. VALIDATION Over 1000 Amp.or Over 600 V FINAL cc B.&P.C.for this reasonBY 0 BRANCH CIRCUIT FEES a Date: 15A,or 20A, 120V,Lighting or Recept. 1 To 10 Branch Circuits W Signature 11 To 40 Branch Circuits ~ El 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 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 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 I certify that I have read this application and under penalty of purjury state TOTAL FEE 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 SIGNATURE OF PERMITTEE DATE