Loading...
HomeMy Public PortalAbout6632 CLOVERLY AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 ! I hereby affirm that I have a.certifica'te of Consent td self CE-806G _ _ APPMCQ 00N •RDR nmrmCAL mmff insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING ARID SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) PolRESS icy No. Company FOR APPLICANT TO FILL IN. JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADD �}r G ❑ 1 & 2-Famil S Ft. $ — $ LOCALITY f Certified copy filed with the county building inspec- y q 'NEAREST tion department. Multi-family Sq. Ft. — `M Residential Swimming Pools CROSS ST. rl , L OWNER OR M Date Applicant :' FIRM NAME 11 t G I LfMAIL CERTIFICATE OF EXEMPTION FROM WORKERS' ( �� ADDRESS � /' COMPENSATION INSURANCE Outlets: Rec Light Sw._ ADD First 20 t7 , -.(This.section need not be completed if the work'involved by Total No. Additional CITY m V G� Tel. No. the permit is for one hundred dollars ($100)or less.) I certifythat in the erformonce of the work for which this PLAN CHECK 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 20 l^Z- ADDRESS i 7 i Total No. Additional Z� �- PPlicant `�� S E—✓�•-�y e CITY Tel. No. Date Fixed Appliances Not Over-1 HP PERMIT �'� NOTICE TO APPLICANT: If, after making this'Certificate 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 Z with comply with such provisions or this permit shall be Top — FAU —W.H. — I , � deemed revoked. Hood Fan _� Other_ CITY _ - Tel. No. LICENSED CONTRACTORS DECLARATION p LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. •— Room Air Cond. _Y__ �r' r REG. NUMBER Class (commencing,with Section 7000) of Division 3 of the BusinessDISTRICT NO. PROCESSED BY and,Professions,Code,and my license is in full force and effect: RPwer Apparatus 8 Large Appliances y 7p ( Size &Type HP, KW, KVA; or KVAR' t�� Q License Number` Lic. Class Up to 1 Incl. FINAL _ U Over 1 to 10 Incl. DATE 1/,0 tK Contractor M S F1 hr_ Date -� —�'ro ; 40 VALIDATION O Over 10 to 50 Incl. FINAL � ❑ I am exempt under Sec. Over 50 to 100 Inc. BY Z I B.&P.C. for,this reason Over 100 of Services, Swbd., MCC &'Panelboards D Z 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 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 2 06-3.-4 A Law for the following reason (Section 7031.5, Business and Professions Code): #.o o•o o.o 2 ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 33,2 5 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 2.0 io 7044, Business and Professions Code). p x 'o'.o 033,2.5 CONSTRUCTION LENDING AGENCY I hereby affirm that there.is a construction lending agency for o 3,2 1 —B3 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 D 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 _ C i Tti% r� L-•i G D $S hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR-EXPLANATORY LANGUAGE. �7:-? Signature o Permittee Date WORKER'S COMPENSATION DECLARATION 20-0079 DPW(12-91) APPLICAT8®tl�'1 FOR ELECT CA PERNT 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,;CSec: 3800 Lab. C.) Policy No. JOB 0�7 CO FOR APPLICANT TO FILL IN ADDRESS Certified copy'is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY40- �A Certified:copy is•filed 1 &2-Family,Sq.Ft. $ $ with the county.building inspection. -NEAREST depa(rt�pent. Multi-family Sq.Ft. CROSS ST. 06 Date Appli Resldental-Swimming Pools ASSESS09 MAP.BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS: OWNER OR Outlets:Rec. Light—/—Sw. / �f IRM NAME G 'COMPENSATION INSURANCE r First 20 MAIL ' .(This section need not be completed if the work involve tl by theADDRESS permit is for one hundred dollars(5100)or less.) Total No. Additional I certify that in the performance of the work for which this permit CITY TeI..No.4//_/ is issued,.l 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, afte,r making this Certificate of CITY Ter.No. Exemption;you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. rovisions of the Labor Code, you must forthwith comply with such PERMIT p y p y Power Apparatus&Large Appliances APPLICANT provisions or this permit shall be deemed revoked, LICENSED CONTRACTORS'DECLARATION" Size&Type HP,KW, V or KVAR DID ESS I hereby affirm that I am licensed under provisions of Chapter 9 _ Over�to 10 Incl. (commencing with Section 7000)'of Division 3 of the,Business and Professions'Code, and my license is in full force and Over 10 to 50 Incl.effect. LICENSE OR f � �© OveP 50 to 100 In . REG.NUMBER Class. Z s O Over 100 DISTRICT NO. P ED.BY License Num Lia Class U Services,Swbd:,MCC&Panelboards ct -ba�v 0-399 Amp.Under 600 V FINAL O ❑Y I am exempt pn f r.Sea • 400-1000 Am Under 600 V V Over 1,000 Amp.P or Over 600 V ��' VALIDATION LU FINAL..' , B:&P.C.for this reasonBRANCH CIRCUIT FEES BY 41 U) Date: .15A,.or 20A, 120V,.Lighting or Recept z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ?3 5' "-` ❑ 41 Or More Branch Circuits _-R_ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits T e- f. SINGLE FAMILY Temp.Power Pole&Appurtenances n- "'' HOME OWNER-BUILDER DECLARATION 31-`'M. Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's.License Law Sig -•r,r,-a; '" �_ for the following reason (Section•.7031.5, Business and Professions Additional Sign.Branch Circuits Code): f '• ids;:`_= j='I ❑ 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) D and Professions Code). CONSTRUCTION LENDING AGENCY Arl 81,17 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 SD 5 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 insp ti purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Af� SIGNAT E OF PERMITTEEP DATE