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HomeMy Public PortalAbout6033 CLOVERLY AVE_Electrical__ ppp� -- WS' COMPENSATION DECLARATION CE 806G 10/81 APPLICATION FOR ELECTRICAL PERMIT L,heF,eby'•pffirm firm that I have a certificate of consent to self insure r a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a cer 1 ied coPYlthereof (Sec. 3800, Lab. C.) Policy No. - Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS V7 v /�• ❑ 1 & 2-Family, S Ft. $ _ $ LOCALITY Certified copy is'filed with the county building inspec- Y, q• tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Date A Residential Swimming Pools Applicant OWNER t G - PP FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE OutRec Light Sw._ ts�ADDRESS , .+H First 20 (This section need not be completed if the work involved by Total No. Additional CITY rc Tel. No. the permit is for one hundred dollars ($100)or less.) that in the performance of the work for which this PLAN CHECK I certify p APPLICANT permit is issued; I shall not employ any person in any manner {� so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First ADDRESS Total No. Additional CITY Tel. No. Date _ —& Applicants w r'lr%�o Fixed Appliances Not Over 1 HP PERMIT p y, NOTICE TO APPLICANT: If, after making this Certificate ofAPPLICANT Exemption, you should 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 shall be Top FAU —W.H. — deemed revoked. Hood Fan _ Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATIONLICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 . Disp. Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES E BY and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances 7( Size & Type HP, KW, KVA, or KVAR' �1 License Number Lic. Class Up to 1 Incl FINA n Over 1 to 10 Incl. DAT J VALIDATION Contractor Date Over 10 to 50 Incl. FIN V ❑ 1 am exempt under Sec. Over 50 to 100 Inc. BY 1L B.&P.C. for this reason Over 100 Services, Swbd., MCC & Ponelboards Date: 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V ElExemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances ;2 2'0 Q,'9 A' HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ,# o o'o oo 2 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and 11- 39.5 0 Professions Code): 1, as owner of the property, will do the work and the Misc. Conduits&Conductors � a o 3 9.5 0= structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 7044, Business and Professions Code). 5, 1 6-,8 5 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE A5? A 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 Permitfee Date --------------------- WORKERS' COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self cE eoeG insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a'c--(�tified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB / QCertified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS (J�_ /� Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY'Ie r� ` tion department. Multi-family Sq. Ft. NEAREST r CROSS Residential Swimming Pools OWNERSOR ®CG UL~ Date Applicant FIRM NAME �TP CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec12—Light b Sw. IMAIL COMPENSATION INSURANCE First ® ,r ADDRESS 1C7 � O (i ET L (This section need not be completed if the work involved by Total No.��= Additional / CITY-'e. ')L� Tel. No. f��Q the permit is for one hundred dollars ($100)or less.) performance of the work for which this PLAN CHECK I certifyn 1 that in the P APPLICANT permit is issued, I shall not employ any person in any manner MA so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ° D ADDRESS ���� Total No. Additional CIT Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT�p� C,�-� �R��0 yp NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Exemption, you should 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 shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NOESSED BY d aP, nd Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVARili �� O License Number Lic. Class Up to 1 Incl. FINAL U r Date Over 1 to 10 Incl. DAT �vl VALIDATION 0 Contracto Over 10 to 50 Incl. `!!!! f- 1 am exempt under Sec. Over 50 to 100 Inc. FINAL U BY LU B.&P.C. for this reason Over 100 d Z Date: Services, Swbd., MCC & Panelboards , Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V 12/ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION I herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit ° P Additional Sign Branch Circuits ` `- °Ir Law for the following reason (Section 7031.5, Business and g Prof sions Code): 3 i I, as owner of the property, will do the work and the Misc. Conduits& Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). , €f` "A L 90 CONSTRUCTION LENDING AGENCY {'[.}E_,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) Ap ® (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name ";il;I_ ti i a PERMIT ISSUING FEE 00 - Lender's Address All 24Z I certify that I have read this application 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 authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ©s WORKERS' COMPENSATION DECLARATION 76A663 10/81 +i h6r by affirrh that J have a certificate of consent to self CE-806G APPLICATION FOR ELECTRICAL PERMIT insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lob. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Q Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. $ — $ LOCALITY 1 tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. CX (✓ Date Applicant OWNER ORr ` ''!!�� FIRM NAME lC�i CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecJaLight4—Sw. MAIL COMPENSATION INSURANCE ADDRESS (Thitid t b s section neenot completed if the work involved b First 20 p y Total No. Additional CITY i r Tel. No the permit is for one hundred dollars ($100)or less.) PLAN CHECK ral 49 1 certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No.�_ Additional CITY � Tel. No. A.RDate Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this C rtificate of APPLICANT Exemption, you should 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 shall be Top FAU —W.H. — deemed revoked. Hood Fan _Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. } (commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PRO D BY and Professions Code, and my license is in full force and effect. Size& Type HP, KW, KVA, or KVAR (/ License Number Lic. Class Up to 1 Incl. FINAL ti= Over 1 to 10 Incl DATE VALIDATION Contractor Date FINAL Over 10 to 50 Incl. I am exempt under Sec. Over 50 to 100 Inc. BY 0- B.&P.C. for this reason Over 100 Z Date: Services, Swbd., MCC & Panelboards 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. r�6 b 5 5.A SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit #.o 0 0 0 0 2 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o,- 27.0.0 Low for the following reason (Section 7031.5, Business and Pro essions Code): Misc. Conduits 8 Conductors o 0 o 2 7.,0 016 1, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— ► 0 7J, 1 2-8 7 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE J Lender'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 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 erm tee —� Date WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 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,khereof(Sec.3800 Lab. C.) Policy NO. Company FOR APPLICANT TO FILL IN ADDRESS ( ❑ L Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITYIr Certified copy 1 &2-Family,Sq. Ft.is filed with the county building inspection _ NEAREST r oc qj department. Multi-family Sq.Ft. CROSS ST. W�,J.aC..l Date Applicant Residential Swimming Pools ASSESSOR PP ''^^ MAP BOOK PAGE PARCEL R OR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.LT Light�Sw._L O � OflM NAME COMPENSATION INSURANCE /7� C �[9 First 20 MAIL (This section need not be completed if the work involved by the Total No. Additional- o� ADDRESS 033 permit is for one hundred dollars($100)or less.) I certify that in the'performance of the work for which this permit CITY Tel.No �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. royisions of the•Labor Code, you must forthwith complywith such PERMIT P Power Apparatus&Large Appliances APPLICANT provisions or this permit shall be deemed revoked. 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 t0 50 Incl. LICENSE OR Over 50.t0 100 Incl. REG.NUMBER Class. a Over 100 DISTRICT NO. PROCESSED BY 0 License Number Lic.Class Services,Swbd.,MCC&Panelboards ® cc FINAL Contractor Date 0-399 Amp. Under 600 V DATE 0 ❑ 400-1000 Amp. Under 600 V I am exempt under Sec. �1 VALIDATION LU Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z Date: 15A,or 20A, 120V, Lighting or Recept. — 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 SINGLE FAMILYr >•`i s Temp.Power Pole&Appurtenances Au •• �� - - HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I � 1139. 11 a 1 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): !I1 At 1 ITEMS •• �• 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TL 1 09 . 1 "1 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ► `sSDa,� °o 11 and Professions Code). FLL1g.Gf CONSTRUCTION LENDING AGENCY )r'Hf C7C aUU 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.) 17�iQil-; 3011 11i 1i : PLAN CHECKING FEE 65IM11=3 Lender's Name PERMIT ISSUING FEE �� 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 E�•y tf1tt� € 1114 Gf� t ordinances and State laws regulating Electrical wiring,and hereby authorize LILLJ –�UU 1 11r 17/7i representatives of this County P property to enter upon the above-mentioned ro ert Art i i 7 fop, spectio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE`;.' ��1- y ;(1 a SIGNATURE OF PERNVITTEE DATE '