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Home My Public Portal About6644 CLOVERLY AVE_Electrical__ WORE;ER'S CON;PENSATION DECLARATION 20-0019 DPW(12-91) APP UCAMN FOR ELECT A LL u�Ju PERNT 76A663 �J 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 JOB �V ElGn ADDRESS GeG Certified copy is hereby furnished.' New Residential Bldgs.&Pools NO. .EACH FEE 1 &2-Family,Sq.Ft. — $ $ LOCALITY £ . ell, Certified copy is filed with the county building inspection _ NEAREST I_ department. Multi-family Sq.Ft. CROSS ST. 04MIAID PSALZ dOd/�'�L� Residential Swimming Pools ASSESSOR 2Xy�} 11 Date Applicant - MAP BOOK. 31 d— PAGE O/V PARCEL . CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light�Sw. FIRM NAME OWNER OR COMPENSATION IN g First 20 / ✓ Af MAIL (�+, / /�'! (This section need not be completed if the work involved by the �(. . ADDRESS (p�p j Z ovr,,Z /TV L 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 42Wbii1 Tel.11or.'7W�3177 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 �0 Q Z. Date Applicant RESIDENTIAL APPLIANCES:NOT OVER 3 HP. NOTICE TO A PLICANT: If, after m ing 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 N� P Y P Y APPLICANT provisions or this permit shall be deemed revoked. Power Apparatus,&Large Appliances LICENSED CONTRACTORS DECLARATION' Size&Type HP,KW,KVA,or KVAR ADDRESS G� 3 Z &M*s P—`41I 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 4Q Tel.No.yV U33 Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE BER Class. } Over 50 to 100 Ind. REG.NUMBER a Over 100 DISTRICT NO. PRO D BY 0 License Number Lic.Class / Services,Swbd.,MCC&Panelboards cc 1� 2 9`�.� 0-399 Amp.Under 600 V FINAL O Contractor .Date DATE ' ' 400-1000 Amp.Under 600 V �� ~ I am exempt under Sec. VALIDATION W Over 1000 Amp.or Over 600 V. FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY d Date: 15A,or 20A, 120V,Lighting or Recept. • Z_ 1 To 10 BranchCircuits Signature 11 To 40 Branch-Circuits El Exemption 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 w for the following reason (Section 7031.5, Business and Profession's Additional Sign Branch Circuits _ -:=•�-` Code): El ^ I,as owner of the property,will do the work and the structure - Misc.Conduits&Conductors —•�•y .:��a is not intended or offered for sale-(Section 7044, Business Other(See Complete Fee Schedule) D 5,4 -' and Professions Code). F`�• r:= 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 F.EE 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 Inspec' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE { SIGNATUR.W PERMITTEE DATE WORKERS'COMPENSATION DECLARATION 76A663 10/8.1 CE-806G APPUC/� (� //� G` MON FO U ELECTRICAL PERIIV T • theraof Sec:3800tLab. C. v h,reb talfirm that I have'a,certificate of consent to self insure,' -or'a oettificate o•oWorkers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY oPY ( ) Policy No. CompanyOR; AP F APPLICANT FILL IN JOB. O Certified copy is hereby furnished New Residential Bldgs.&PoolsEACH NO.' FEE 'ADDRESS' ` V• � C"'tifiecl copy is filed'with the county..building inspection 1A-2-Family;Sq.Ft. $ _ $ LOCALITY NEAREST,. department Multifamily Sq.Ft. CROSS ST,. fid» e.. + Residential Swimming Pools' ..Date ' - ' Applicant • _ - OWNER OR -. , FIRM NAME, ' 6�1.N. ; CERTIFICATE OF EXEMPTION'FROM WORKERS"` MAIL Outlets:Rec ' Light Sw. / /� COMPENSATION'INSURANCE First 20 6O' ADDRESS 66LI t (This section need not be'completed if the'work involved by the CITY .Tel.No.' permit.is for one hundred dollars ($100)or1ess) ,Totel No. Additional I certify that'in the performance of the work-.for which this permit gppNICANT CHECK is issued; I shall not employ, any,person in any manner;so.as'to' . become subject to the Workers'Compensation,-Laws: Lighting Fixtures Fiirst 20:., ADDRESS Date : . .' Applicant o. Ove a ,To, N Adds CITY Tel No. Additional FixedRange IianceHeaoter_r D.W. PERMITAk •E emptionT you should become subjeect So thenWorkers,;Ce'Mat anon 9 APPLICANT. f provisions of the Labor.Code,you must fgrthwith comply with such. Oven Dryer _ W.M.,._ .;, ADDRESS 44C- -provisions or this permit shall be deemed revoked. Top FAU W.H. —, CITY ' Tel.No: LICENSED CONTRACTORS DECLARATION L• _ye/G Hood Fan Other_ I h4eby affirm.that-I.am licensed 'under-provisions of Chapter 9LICENSE;oR (commencing:with Section 7000),of Divisom3.of the Business and Disp. Room Air Cond.. > rrC lj(�� REG.NUMBER '�',Class.,��O Professions Code,and my license is in full force'aiid effect. er Appa atus f & Large Appliances DISTRICT No..,, PROQE9§ BY Size&Type HP,KW,.KVA,or KVAR 0S 0 License Number- - Lic.-Class CIO Up tol Incl. FINAL V Over.ilto)0 l`t�I rIncl DATE ✓� Contractor � �"c.'- t°��C Date' t VALIDATION Over 10 to 50 Incl FINA V ,.I am exempt.under Seca Over 50 to 100 Inc. BY Over 100 B.&P.Ca for this reason - Services, " :- a. ..'' - a. Services,Swbd.,MCC'.& Panelboards Z,. �/� , ��Date'y P 0-200 Amp.Under 600 V h Signature a �/ 201 - 1000 Amp,Under 600.V Q Exemptiontr.• Over 1000 Amp..or.Over 600 V ,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 Law ' for the.following,reason(Section.7031.5,B 'Additional Sign Branch Circuits usiness and Professions Code): Q I,as owner of the property,will do the work and the structure M ductors sc'Conduits& Con 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 8 b a 6,A performance of the work for which this permit is issued(Sec.3097; PERMIT FEE (Sub=Total) Civ.C.). Co`� 1.7.5 O PLAN CHECKING FEE Lender's,Name o>o 6 1 7.5 O c=.) PERMIT ISSUING FEE Lenders Address 1230'.`$7 I certify that I have read this application and state that the above TOTAL FEE 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 " prop for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date '