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HomeMy Public PortalAbout4908 DOREEN AVE_Electrical__ WORKERS' COMPENSATION DECLARATION IO/8I I hereby affirm that I have a certificate of"<onsert to self CE-806G APPLICATION caSLICATION FOR ELECTRICAL PERMIT insure, or a certificate of Workers' Compensatioq Insurance,- - - ,COUNTY OF LOS ANGELES T (' BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C:) / / Policy No. Company FOR APPLICANT TO FILL IN JOB D O Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Residential Swimming Pools OWNER OR Date gpplica of FIRM NAME V CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight Sw� ;�! EMAIL COMPENSATION INSURANCE 0 ADDRESS - (This section need not be completed if the work involved by /� �} First 20 the permit is for one hundred dollars,($100)or less.) Total No. Additional 3 LTY Tel. No. PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner f so as to become subject to'ihe Workers'Compensation aw . Lighting Fixtures First 20 ADDRESS ' ' Total No.- Additional CITY Tel. No. Dale R� ^/a-IdApplicant / Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Ce'tificang of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater_ .W. _ Compensation provisions of the Labor Code, you must forth Oven — Dryer W.M.— ADDRESS S^Ly/if with comply with such provisions or this permit shall be Top — FAU —W.H. CITY / Tel. No. � deemed revoked. Hood _ Fan _ Other LICENSED CONTRACTORS DECLARATION 3 ,-'U LICENSEWR ''^^ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Card. REG. NUMBER' 3 V Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES D BY Power Apparatus &large Appliances p� ~ > and Professions Code,and my license is in full force and effect. � 0 Y ` O Size & Type HP, KW, KVA, or KVAR' O License Number 0 Lic ClassUp to 1 Incl. FINAL DATE Contractor J'J 0 Contractor Over 1 to 30 Incl, VALIDATION Date�� Over 10 to 50 Incl. FINAL L/ 0 ❑ I am exempt under Sec. Over 50.to 100 Inc BY W Over 100 Z 8.8P.C. for this reason /// Date: Services, Swbd., MCC& Panelboords 0 -200 Amp. Under 600 V D ' Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. MaOver 1000 Amp. or Over 6D0 V inl. Elect. ' SINGLE FAMILY Temp. Power Pole 8 Appurtenances .e HOME OWNER-BUILDER DECLARATION 435 1.8 A Sign with One Branch Circuit f hereby affirm that I exempt from the Contractor's License Additional Sin Branch Circuits 5 `Z Law for the followingg r reason (Section 7031.5, Business and g 1' � ' Professions Code): 2o.- 4 4 7'5 ❑ Misc. Conduits 8 Conductors as owner of the property, will do the work and the s ,e o s'4 4!7 5 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 6� - � 7044, Business and Professions Code). � '18-4' 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 �O ' 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 Stole 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 Date c \VORKERS'COh1PENSATION DECLARATION 63 CE 8O6G 12 801 APPLICATION FOR ELECTRICAL PERMIT _ CE 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 FILL IN JOB Policy No. Company New Residential Bldgs.& Pools EACH NO. FEE ADDRESS Qa ��Q fv Qp 54- ❑ _ ` Certified copy is hereby furnished. 1 &2-Family,Sq. FL $ � $ LOCALITY Certified copy is filed with the county building ms pectien CROSS ST Multi-family Sq. Ft. — NEAREST p,qr •a p t2 t(So._ department. Residential Swimming Pools OWNER OR FIRM NAME ( SN O cl Dale Applicant Outlets: Rea_Light_Sw._ MAIL / yy First 20 ADDRESS / -3 X V Y CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY `-(ytCa r-C, Tel No. pyy COMPENSATION INSURANCE PLAN CHECK �- (This section need not be completed if the work involved APPLICANT O by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS Total No. Additional ¢ I certify that in the 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 I PERMIT - r so as to become subject to the Workers'Compensation Laws. Range_ Heater_D.W. APPLICANT 1 Oven _ Dryer-W.M._ ADDRESS N Date � Applicant Top _ FAU _W.H.. ' Z Hood _ Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ T _ LI ROO "Air Cond. CENSE 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. 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 LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE Over 10 to 50 Incl. VALIDATION ` I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL /n 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 1 ' - effect. Services /3o c U 0.200 Amp. Under 600 V License Number Lie.Class - 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATIONO 2 3..7 A' Temp.Power Pole& Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit - # oo,Ye e 2 License Law for the following reason (Section'7031.5, Busi- Additional Sign Branch Circuits - 2 e,o 2 3.5 0 ness and Professions Code): Misc. Conduits&Conductors _ o o e 2 3,5 0,F!® 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 0 -7.,07-81 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sce..3097.Civ.C.). ' ZV Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel Lender's Address PERMIT ISSUING FEE ' I certify that I have read this application and state that the TOTAL FEE 3 SZ above information is correct. 1 agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this Countv to enter upon the above-men tio/le roperty for inspection purposes. / / SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ' hWOR .I have COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT IJ I ereby affirm thatathavevea certificate of consent to self insure, 6A663 or a certiNcale of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.f 3600 Lab.,C.) Policy No. Company FOR APPLICANT TO FILL IN JOADDB RESS V/t O' ❑ JFA Cartitietl copy is hereby furnishetl. New Residential Bldgs.8 Pools NO. EACH FEE LOCALITY ❑ Certified copy is filed with the county building inspection 1 IS 2-Family,Sq.Ft. $ S department. Multi-family 9�S Ft. NEAREST C CROSS BT. G J� Data Applicant Residential Swimming Pools ASSESSOR �77__ •MAP BOOK ppGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' •Outlets:Rec.L Light Sw.L OIWNEAOR �' COMPENSATION INSURANCE 'First 20 (This section need not be completed if the work Involved by the G MAIL Lt Q permit is for one hundred dollars(5700)or less.) Total No. Additional ADDRESS Q/ 1� 1 certify that in the performance of the work for which this permit CIN TeL N QO� (, fill is issued, I shall not employ any person in any manner so as to PLAN CHECK VV become subject to the Workers'Compensation Laws. Lighting Fixtures 7 o First 20 v APPLICANT �L /}/j� Total No. 4'V Additional ADDRESS Data " Applicanl�poy T A RESIDENTIAL APPLIANCES NOT OVER 3 HP. ' NOTICE T PPL CANT: If, after m—�ihis 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 O t.l - provisions or this permit shall be deemed revoked. Power Apparatus&Large AppiiSnces APPLICANT 'V N LICENSED CONTRACTORS DECLARATION Size&Typ HP,KW,KVA,or KVAR j� ADDRESS L 1 hereby affirm that 1 am licensed under provisions of Chapter 9 � Over 3 to 10 Incl. c+• If 7 (commencing with Section 7000) of Division 3.of the Business 5nd CITYL-Ar-7Tel. Professions Code,and my license is in full force and affect. nc1.Over 10 to 501 �. LICENSE OR L / Class. d Over 50 to 100 Incl. REG.NUMBER ri 6 C LQ O D Over 100 DISTRICT NO. P SED BY License Number�Lic.Class V Z rye} Services.Swbd.,MCC&PanelboardsO7y Q ls ContractorT�� I I G�oDa s B " r- 0-399 Amp. Under 600 V DINE am exempt under Sec. 400-1000 Amp.Under 600 V V ❑ Over 1000 Amp.or Over 600 VFINAL VALIDATION LU B. &P.C.for this reason BRANCH CIRCUIT FEES BY U) Date: 15A,or 20A,120V,Lighting or Recept. z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits F-141 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A.20A,206V To 277V Ughlmg Br.Circuits SINGLE FAMILY Tamp.Power Pole&Appurtenances i HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit HC•l.i a I hereby affirm that I am exempt from the Contractor's License Law r'' for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits _130 j L;14 7 3 Code): C., F1 1, -1, as owner of the property, will do the work and the structure Misc.Conduits&Conductors. t ee�o� is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) gip y© TOTAL = 95 c and Professions Code). C HECK CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the C.HANIGE •�)'-1 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) ' PLAN CHECKING FEE I]I]Qfj-Til]L Ci LJ!F t Lender's Name PERMIT ISSUING FEE All O 6655 _ PIN `I% Lender's Address / /� I certify that I have read this application and under penalty of purjury state TOTAL FEE (� /J- 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 sl URE OF MITTEE DATE