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HomeMy Public PortalAbout4934 DOREEN AVE_Electrical__ r: WORKER'S COh$ENSATIOvNDECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I,hereby affirm that I have of certificate of consent to self insure, 76A663 or'a;certificate of Worker's Coni tion Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC,WORKS BUILDING AND SAFETY DIV. ; copy thereof(Sec. 3800 Las.C) Policy N0. Company FOR APPLICANT TO FILL IN J06 yq ADDRESS "� I . Certified copy is hereby furnished New Residential Bldgs.&Pools NO. EACH FEE -- - - _ C Certified' with the county building inspection _ 1&2-Family,Sq. FL $ $ LOCALITY 'NEAREST 1 department. Multi-family Sq.Ft. CROSS ST. Date ''Applicant Residential Swimming Pools _ ASSESSOR /TT ✓. MAP BOOK PAGE PARCEL ;CERTIFICATE OF EXEMPTION FROM WORKERS' - / v -0-- (y. M OWNER OR _ COMPENSATION INSURANCE .• Outlets:Rae/ LightSw. d FIRM NAME - ' 9/1•�/ First 20 MAIL (This.section need not be completed if the work)mvolved'by the Total No. Additional° - ADDRESS 9 permit is for one hundred dollars(S10O)or less.) 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 y., fi become.subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN CHECK I P 9 g APPLICANT Total No. Additional ADDRESS Date�0----- Applicant - v RESIDENTIAL APPLIANCES OT OVER 3 HP. ' �� NOTI E.TO,C APPLICANT: If•, after making this Certificate of CITY T.I.No. Exemption,you should,become subject to the WorkersCompensation 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 // S- 1717 I hereby0affirm thahl-am licensed under provisions of Chapter 9 Over 3 to 10 Incl. q (commencing with Section 7000) of Division 3 of the Business and CITY T .No. � 6 L Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. " � LICENSEOR 17,)L Class. CID d �F Over 50 to 100 Incl. REG.NUMBER �C/ `+/v License Number Lia Class Over 100 . DISTRICT NO, PR SSED BY O IIIVJJJ 'Services,Swbd.,MCC&Panelboards ap' ,L" -tea/ Q 0-399 Am Under 600 V FINAL O COi1IraCIOr °' N.L]f —. P DATE 400-1000 Amp.Under 600V xp pp ~ ' ❑ am exempt under Sea C'3—%3 v VALIDATION LU Over 1000 Amp.or Over 600 V FINAL W t - BAP,C.for this reason - - BBY / BRANCH CIRCUIT FEES Date: VT—' � 15A,or 20A, 120V,Lighting or Recept. Z J. 1 To 10 Branch Circuits Signature11 To 40 Branch Circuits - ❑ Exem41 Or More Branch Circuits ption for Reg.Maint.Elect. 15A.20A,208V To 277V Lighting Br.Circuits - .SINGLE FAMILY Temp. Power Pole&Appurtenances Hj_.;T,2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit c I hereby affirm that I am exempt from the Contractor's License Law 3`h ,6_I°.1cc'. for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code). ....� _ I ITEC','= . - ❑ I, as owner of the property,will do the work and the structure .Mist.Conduits&Conductors _ TOTAL 65 EE 55 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ and Professions Code). D.. "' 1;1'Euk _Lc°`I f' A4iir CONSTRUCTION LENDING AGENCY ". ._I jp.I p1E 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 1d1 Af. s•. 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 inspect n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE DATE WORKER'S haveCOMPENSATION DECLARATION 76A669 DPW(,2-9„ APPLICATION FOR ELECTRICAL PERMIT IJ 0-001 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,(See.,3800 Lab.C,) - - - Policy No Company - FOR APPLICANT TO FILL IN JOB ADDRESS Ii-IiET ❑ 'Certified'copy is hereby furnished. - New Residential Bldgs.&Pools NO. EACH FEE LOCALITY C El 1 8 2-Family,Sq.Ft. $ $ ertified copy is filed with the county building inspection NEAREST , department Multi-family Sq. Ft. caosG RT. Date Applicant Residential Swimming Pools ASSESSOR - MAP.BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR v • Outlets:Rec.—Light Sw._ FIRM NAME COMPENSATION INSURANCE - fG �— a' •n, .First 20 MAIL (� (This sectlon need not be completed if the work Involved by the Total No: Additional ADOREGS T p ye Q h permit is one ne hundied dollars($100)or less:) I certify that In the performance of the work for which this permit - - ' ` CIN Tel.No.41q 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 Date "' - ApplicantRESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE:TO APPLICANT: If, after making this Certificate of 1.; 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 8 Type HP.KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions.of Chapter 9 Over3to 101nc1. (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. Y Over 50 to 100 Ind. LICENSE Class. d REG.NUMBB ER Over 100 DISTRICT NO. PRO SSED BV O License Number Lic.Class U s, &PaPelboards Q O CC Contractor Date ' �39 .U`/fd/er 600 V pATE ❑- - -' I am exempt under Sec. 400-1000 Amp, Under 600 V $—Z - 3` VALIDATION Q UJI Over 1000 Amp.or Over 600 VFINAL 7 d B.&P.C.for this reason BRANCH CIRCUIT FEES BY W - Date: 15A,or 20A, 120V,Lighting or Recept. .. Z - - - 1 To 10 Branch Circuits - Signature 11 To 40 Branch Circuits - - - - 41 Or More Branch Circuits - Exemption'lor'Reg.'Maint Elect 15A,20A,208V To=V Lighting Br.Circuits SINGL@FAMILY Temp.Power Pole&Appurtenances - HOME OWNER-BUILDER DECLARATION -' i`('T 'a' I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit hi=n+� •IF , for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits --S.i Jt _,:�x.i_l Code):- - LI/f I, as owner of the property;will do the work and the structure Misc.Conduits Conductors _- 1 !Tt(i�- is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) © r t and Professions Code). _ - k')IAyL, 6_3Ei �5 _ CONSTRUCTION LENDING AGENCY _ t�-r, 6 .415.4 1 1 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) 5 Civ. ct - - PLAN CHECKING FEE ...-.. ,l lel l-illJj.!1 1. r.1 Lender's Nam _ � � ' PERMIT ISSUING FEE "'-' - Ily`7] i- - Eiil ;�=7;_, Lender's Address I certify that I have read this application and under penalty of perjury state TOTAL FEE 5•� T - - that the above information is correct. I agree to comply with all County - ordinancesandStatelawsregulatingElectricalwiring,and herebyauthorize repre,entatives of this County to enter upon the,above-mentioned property for action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I IATORE OF PERMITTEE HATE 76AGee.CESDB.10.56 APPLICATION FOR ELECTRIC PERMIT BUILDING AND SAFETY DMSION Depox went of County Engineer BUILDING A v County Of LOS Angeles ADDRESS /*' JOHN A. LAMBIE. COUNTY ENGINEER CASSATT D. GRIFFIN. SUPT of BUILDING LOCALITY NEAREST b �1 FOR APPLICANT TO FILL IN CROSS ST. / r 1fL 17. Q. PERbIIT FEES OWNER p LIGHTS RECEPTACLES SWITCHES /I� Aa NUMBER I T E M EACH FEE MAIL EBB ;1' /{P x>o j/e a 1T *y e TOTAL OUTLETS $ .10 5 D ELEC. RANGES, WATER HEATERS, CITY 10a 7/✓ el'A" TEL. NO. I a/ CLOTHES DRYERS .50 ELEC. SPACE HEATERS, STAT-Y. COOK- ELECTRICJIAN " -}. INS UNITS, GARBAGE DISPOSERS, ADDRESS / AUTO WASHERS. DISHWASHER .25 LIGHTING FIXTURES .10 L° iv W TEL. NO. MOTORS STATE LICENSE NO. HORSEPOWER H.P. DISTRICT GROUP ZON READY FOR INSPECTION OVER INC. %a B LESS .25 1h — 2 50 INSPECTION R CORD 2 5 1.00 5 IS - 1.50 15 50 2,50 SO 200 5.00 M18C. tl SIGNSI NO.TRANS NO. LAMPS SERVICE 0.500V 1.00 SERVICE OVER 500V 5.00 WIRING PERMIT 1.00 Q FIXTURE PERMIT 1.00 SUPPLEMENTARY PERMIT .50ii� APPROVALS TOTAL FEE DATE• INSPECTOR'S SIGNATURE IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELECTRICAL WIRING. WIRING 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES ){ • �i '� LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF , CALIFORNIA OR THAT 1 AN THELEGAL OW OF THE ABOVE POWER DESCRIBED RESIDENd OPERTY. I afGNATURF UTILITY CO. NOTIFIED PERMITTEE FINAL JOHN A `/j{I,jDA ARTHUR C. VETT. ENGINE COUNTY ENGINEER CN Mo CASH SUPERVISING ELECTRICAL ENGINEER L AC01 7 1 5,� AUG 27 2 2.4 5j R. WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) 1 hereby affirm that I have a certificate of consent to self Insure. 7aMN APPLICATION FOR ELECTRICAL PERMIT VVV 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 ADDRESS Certified copy is hereby furnished. New Residential Bldgs.8 Pools NO. EACH FEE LOCALITY Certified c 1 8 2-Family,Sq.Ft. ❑ copy is filed with the county building inspection department. Multi-family Sq.Ft. NEARESTCROSS ST. Date Applicant Residential Swimming Pools MAPEBOOK PARE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE DDfefs:Rec. Light_SW._ FIRM NAME (This section need not be completed 11 the work Involved by the First ADDDRESS 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 t0 PUN 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, 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 8 Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size 8 Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to t0 incl. (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. d Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. 0 LICENSE Over 5010 100 Incl, REO.NUMBS Class. ER (� Over 100 DISTRICT NO. PROCESSED BY W License Number Lic.Class _J Services,Swbd.,MCC 8 Panelboards LL Contractor Date 0-399 Amp.Under 600 V FATE >_ ❑400-1000 Amp.Under 600 V 1 am exempt under Sec. VALIDATION 9 Over 1000 Amp.or Over 600 V FINAL B.BP.C.for this reasonBRANCH CIRCUIT FEES BY d Date: 15A,or 20A,120V,Lighting or Recept. 12 1 To 10 Branch Circuits W Signature 11 To 40 Branch Circuits ~ ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,20 VV To 277V Lighting Br.Circuits SINGLE FAMILY Temp,Power Pole 8 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, Business and Professions Additional Sign Branch Circuits Code): ❑ 1,as owner of the property,will do the work and the structure Misc.Conduits 8 Conductors 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 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 Lentlar'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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE DATE