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Home My Public Portal About10910 DAINES DR_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LI 6A663 I heyeby 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 thereob(Sec.f3800 Lab.,C.) Policy No. Company FOR APPLICANT TO FILL IN ADDRESS 1 el ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY ❑ Certified co is filed with the count building inspection 1 &2-Family,Sq.FL — $ $ PY Y 9 P NEAREST department. Multi-family Sq.FL CRosS ST. Date Applicant Residential Swimming Pools _ ASSESSOR o,(— MAP BOOK O +taJ PAGE O PARCEIL99 /G CERTIFICATE OF EXEMPTION FROM WORKERS . OWNER CR COMPENSATION INSURANCE Outlets Rea Light Sw. �} FIRM NAME need First _ MAIL 11 (This t Is for need not be completed 0 the work involved by the ADDRESS �� G, N 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 to PLAN CHECK !1J become subject,to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. 24 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 Over 3 to ii)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 Ind. LICENSE OR } Over 50 to 100 Incl. REG.NUMBER Class. d License Number Lic.Class Over 100 DISTRICT NO, P SSED B� 0 Services,Swbd.,MCC&Panelboards `�•191 Q Contractor Date 0-399 Amp, Under 600 V FINAL Q- ❑ 400-1000 Amp.Under 600 V DATE I am exempt under Sec. VALIDATION V Over 1000 Amp.or Over 600 V FINAL - LU B.&P.C.for this reason EL BY BRANCH CIRCUIT FEES Date: 15A,or 20A, 120V,Lighting oc Recept. Z - - - 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits - 41 Or More Branch Circuits Exemption for Reg. Mardi.Elect: 15A.20A,208V To 277V Lighting Br.Circuits 2 SINGLE FAMILY Temp.Power Pole&Appurtenances _- y a HOME OWNER-BUILDER DECLARATION A(_i+I ea _ I hereby affirm that n with One Branch Circuit exempt from the Contractor's License Law Sig ..._.. cG I for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits • i ITEMS1, as owner of the property,will do the work and the structure. Misc.Conduits&.Conductors - e. 0 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) - - Ti ITRL and Professions Cade). _ p r e0 ^�r -HEIk; CONSTRUCTION LENDING AGENCY _��f'E1dE 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) 3 Q Civ. C.) PLANCHECKING FEE ""/ 27r5= Lender's Name PERMIT ISSUING FEE pa �. 1 ti11iL Lender's Address 1 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 452 SIGNATURE OF PE MITTE ATE i WORKENS'COMPENSATIONDECLARATION 76A866 63 (2-80) CE G APPLICATION FOR ELECTRICAL PERMIT {� u 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.) //rs Policy No. Company FOR APPLICANT TO EACH N NO. FEE ADDRESS (V ) New Residential Bldgs. &Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITYlUpC Multi-family SqFtNEAREST Certified copy is filed with the county bu . Ft.—inspection CROSS ST S department. - Residential Swimming Pools OWNER OR I FIRM NAME r•IC Datx Applicant Outlets:,Rec._Light_ Sw.— AMAIL DDRESS `- / _ _ _ _ _First 20 _ _ __ _ _- _. _ __. _ _ - --GE RTI FICCOMP COMPENSATION OF-EXEMPTION-FROM CE KERS'' _- - -Total No. Additional CITY Tel No. 3•. } - COMPENSATION INSURANCE PLAN CHECK a ' (This section need not he completed if the work involved APPLICANT AvU by the permit is for,one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS " Additional c' 1 certifythat in the T1.otal No. Q performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. Permit is issued, I shall not employ any person in any manner PERMIT W Boas to become subject to the Workers"Compensation Laws. Range_ Heater_D.W. APPLICANT d N Oven _ Dryer_W.M._ ADDRESS z Date Applicant - Top' _ FAU _W.H. — Hood — Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Dista. _ Room Air Cond.— LICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. _ PROCESED BY with comply with such provisions or this. permit shall-be deemed revoked. Size&Type HP,KW, KVA,or KVAR - Up to 1 Incl. FINAL Over 1 to 10 incl. DATE Z^.zi, VALIDATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. 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 ness and Professions-Code, and my license is in full force and effect. Services - 0-200 Amp. Under 600 V License Number. Lic.Class 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATIONI. - Temp. Rt3wer Pole& Appurtenances I hereby affirm that [ am exempt from the ContractorSign with One Branch Circuit 's additional Sign Branch Circuits S 7 O At License Law for the following reason (Section 7031.5, Busi- ness and Professions Cade): - r ❑ Misc.Conduits& Conductors #,e e'o o e 2 I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 2 e�0 23 S O structure is not intended or offered for sale (Section 7044, Business and Professions Code). y CONSTRUCTION LENDING AGENCY efe o,2 3 S O v I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit isPERMIT FEE (Sub-Total) / 0823'-82 issued (Sec. 3097,Civ.C.). ! Lender's Name PLAN CHECKING FEE (One�Fourth Permit Fee) . Lender's Address PERMIT ISSUING FEE V 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 here v-arrt 'ze representatives of this County to enter upon t e Bove-men[ d pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE rgnature of Permittee Date '