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Home My Public Portal About10709 DAINES DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 CE 806G 12801 APPLICATION PPLICpTION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent'to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or ' a certified copy thereof(Sec. 3800, Lab. C.) FOR APPLICANT TO FI LL IN JOB Policy No. Company EACH NO. FEE ADDRESS 107f7 An ❑ New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-FamilySq. Ft. O $ $ LOCALITY �pC,c�7 fE 617 ❑ Multi-family Sq. Ft. • NEAREST - Certified copy is filed with the county building inspection CROSS ST AA department. Residential Swimming Pools OWNER OR _ FIRM NAM EI) - �L Date Applicant Outlets: RecaLiglit-9See.� AIL First 20ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. 3 Additional CITY - Tel No. COMPENSATION INSURANCE - } PLAN CHECK 1 (This section need not be completed if the work involved APPLICANT O hit Lighting Fixtures First 20 by the permit is for one hundred dollars (5100) or less.) ADDRESS Additional Q Total No. -I certify that in the performance of the work for which this CITY Tel No. p Fixed liances Not Over 1 HIP F permit is issued, I shall not employ any person in any manner - 'PERMIT Ai-i" C W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT L C 4 a Oven DryerW.M. ADDRESS to Date Applicant Top _ FAU _W.H., r Z CITYYel No[ q Hood _ Fan _Other_ � D � 'Ssy / NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond._ I LICE EOR , Exemption, you should become subject to the Workers' I EG. NUMBE R'3, ]7 Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances' DISTRICT NO. PROCESSED BY with comply. with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR deemed revoked. Up to 1 Incl. FINAL ^ Over 1 to 500 1 In. DATE 4 LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. - —I VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 - BY qJ - ness and Professions.Code,and my license is in full force and _ effect. Services ` I License Number Lic.Class 0-200 Amp..Under 600 V201- ^ �7 7 201-1000 Amp. Under 600 V I(`0„ \ / ' Contractor Date' Over 1000 Amp,or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that 1 am efrom the Contractor's License Law for the followingg reason Additional Sign with One Branch Circuit n (Section 7031.5, Busi- n Branch Circuits , ness and Professions Code): Misc.Conduits&Conductors ':2 9 6 2 9 0 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— structure is not intended or offered for sale (Section - ,e e'e e`o.2 7044, Business and Professions Code).' ' CONSTRUCTION LENDING AGENCY PTO °,5 1, 5 0 I hereby affirm that there is a construction lending agency for the performance of the work for which [his'permit is - °•° ° 5 1.'S O'er issued (Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total) Lender's Name— � �X� PLAN CHECKING FEE (One-Fourth Permit Fee) - 0 2,0'8-8 3 Lender's Address PERMIT ISSUING FEE 1 certify that 1 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 thea ove-mentio a property for inspection purposes. - +{/'//❑o S SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of ermit[ee 3 Date_�� WORKERS'COMPENSATION DECLARATION i76.663 ,G,B, APPLICATION FOR ELECTRICAL PERMIT {� I hereby-affibm that 1 have a certificate of gons,ent N,self insure, CE-806G �J or a certificate of Workers' Compensation Insurar(ce, or-a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3600.Lab. C.) _ Policy'No. Company FOR APPLICANT TO FILL IN FNEAREST 0{'J6 , N C ❑ Certified copy is hereby furnished. .EACH NO: FEE S J r , New Residential Bldgs.&Pools ❑ -Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $ Y 12:B PLE C - department. Multi-family'Sq.Ft- — T.Date ApplicanP Residential Swimming Pools ORCERTIFICATE OF'EXEMPTION FROM WORKERS` , ` y :FRMEOutlets:REc Ligh[ Sw. -COMPENSATION INSURANCE - "V SFirst 20(This section need not be completetl ii the work involvedby the ) �yXIao- Tel.No. a!9 permit is for one hundred dollars($100) or less.) Total No. Additional 1 certif that in the erformance of the work for which this ermit PLAN CHECK - APPLICANT is issued, I shall not employ any person in'any manner.so as to - - become subject to theWorkers'Compensation Laws. - Lighting Fixtures First 20 ADDRESS Additional Total No. ` l J. - CITY •Tel,No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of , Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthh.comply.with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be dwit deemed revoked. .. Top — FAU W.H. _ _ . LICENSED CONTRACTORS DECLARATION Hood Fan Other_ CITY Tel.No. , I hereby affirm that I am licensed under,provisions of Chapter 9 - 0 LICENSE OR ' (commencing with Section 7000) of Divisicn•3`of the Business and Disp. — Room Air Cond. REG.NUMBER Class. Professions Code,and my license i5 in full force and effect. ' DISTRtOT NO. PROC D BY ,Power Apparatus 8 Large,Appliances /h'-' Size & Type HP,KW,KVA,or KVAR ` -/ ' D 01 License Number Lic.ClassUp To 1 Incl FINAL U Over 1 to 10 Incl. DATE �t VALIDATION Contractor Date Over 10 to 50 Incl. (l �- H E] FINAL am exempt under Sec. Over 50 to 100 Inc. BY W �- B& Over 100P.C. for this reason N Services, Swbd.,MCC & Panelboards - Z Dale: 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 - r14C•I �v Sign with One Branch Circuit hereby affirm that I am exempt from the Contractor's License Law 3307 41.h for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits. Code): 1 ITEMS EIS 19 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) TOTAL m and Professions Code). NECK 4I,1'J CONSTRUCTION LENDING AGENCY - C.HAtdGE ,'h! I hereby affirm that there is a construction lending,agency for the performanceof the work for which this permit is issued(Sec.3097, PERMIT FEE - - (Sub-Total) - Civ.C.)r PLAN CHECKING FEE _ 1131300-UC+01 b! 1191' Lender's Name PERMIT ISSUING FEE 11163 . 1 AM $74.: Lender's Address .1 certify that I have read this application and state that the above TOTAL FEE lit Information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize. r resenfslaves o this Cou ty to core; upon the above-mentioned - perty , r in p ction pur sea. / SEE REVERSE FOR EXPLANATORY LANGUAGE , . ignatur f ermittee Date