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Home My Public Portal About4523 ELLIS LN_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 WI ley tldo/r�i1PI�L��sAT�®Iltl FOR IEL ECTMCAL PERNT - �f I hereby affirm that l have a certificate of consent to self insure, or a certifica[e of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Seo. 3800 Lab. C.) Policy NO. Company FOR APPLICANT TO FILL IN JOB ADDRESS -Certified copy is hereby furnished: New,Residential Bldgs.&Pools NO. EACH FEE LOCALITY El1 &2-Family,Sq.Ft. — $ $ Certified copy;is filed with the county building inspection _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools J MAPEBOOK, PAGE PARCELD P WNER OR CERTIFICATE OF EXEMPTION FROM WORKERS'. utle s:Rec.�Light Sw. J / FOIRM NAME COMPENSATION INSURANCE - First 20 MAIL (This section need not be completed if the,work involved by the Total No. _... Additional ADDRESS permit is'for one hundred dollars($100)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 PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20. p APPLICANT - � /^ Total No. Additional ADDRESS. Date /� Applicant �� } NOTICE O APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. 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 APPLICAN LICENSED CONTRACTORS DECLARATION' Size&Type HP,KW,KVA,or KVAR ). ADDRESS a A1.6 w Ad, I hereby affirm that-I am licensed under provisions of Chapter 9 � �quer 3 to 10 Incl. / �a (commencing with Section 7000) of Division 3'of the Business and / CITY �� 74V, Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. 7 -_ LICENSE OR L'% Over 50 t0 100 Incl. REG.NUMBER _7 class. /� / Over 100 DISTRICT NO. PROCESSED BY O License Number Lic.Class Services,Swbd.,MCC&Panelboards `oI� 0-399 Amp.Under 600 V FINAL O Contra a DATE Q El 400-1000 Amp.Under 600 V Z^ / U I am exempt under Sec. VALIDATION LU Over 1000 Amp.or Over 600 V FINAL d B.&P.C.for this reasons BY I) BRANCH CIRCUIT FEES D e: '.� /� 15A,or 20A, 120V in or Recept. h a + Z `� � 3 - 0 10 Bra ch Circuits �� ' " Signature .3 11 To 40 Branch Circuits El Exemption Or More Branch Circuits ANT.7._-.. _• Exemption for Reg.Maint.Elect. 15A,20A,208V To 277,V Lighting Br.Circuits j 7 d SINGLE FAMILY Temp.Power Pole&Appurtenances d ITEMS HOME OWNER-BUILDER DECLARATION - 1 I i Ef 1S I hereby affirm'that I am exempt from the Contractor's License Law Sign with One Branch Circuit T 4t for the following reason (Section 7031.5, Business and Professions Additional.Sign Branch Circuits TOTAL gar 4-_s Code): ' 3 t ❑ 1, as owner of the property,will do the work and the structure �[ Misc.Conduits&Conductors � �1�1vnC is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) �•HAIYis� .00 and Professions Code). CONSTRUCTION LENDING AGENCY S.F',900-0t.i01 12f30 r'.' 1 hereby affirm that there is a construction lending agency for the tt� i tt performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) t✓L 17 . 3 Ali 8:511' Civ. C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE p1/ Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE �0 • 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 - WORKERS' COMPENSATION DECLARATION 76A669ovw3ie7 n PP��C ^ �( MN -FOR ELECI^UCAL PERNT O I'hereby affirm that I have a certificate of consent 4o self XE-806(3 (� (� insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lamb. C.) Policy N Company�Td� �� FOR APPLICANT TO FILL IN JOB. ertified copy is hereby furnished. New Residential Bldgs. & P s EACH NO. FEE ADDRESS r_1 Certified co is filed with the count building ins e - 1 &2-Family, S Ft. - $ — $ LOCALITY PY� Y 9 � P y- q� tion department. 'Multi-family Sq. Ft. — NEAREST CROSS �_�3-c�� Pp esidential Swimming Pools OWNERST.OR / Dat' A lic FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL { o. COMPENSATION INSURANCE ' First 20 ADDRESS o2 (This section need not be completed if the work involved by Total No. Additional. CITY Tel. No. Additional— the permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this PLAN CHECKAPPLICANT permit is issued,,I sholl notemploy any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to The Workers'Compensation Laws. Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of 'APPLICATION Al C` Exemption, you should become subject to the Workers' Range— Heater—D.W. tV Compensation provisions of the Labor Code, you must forth- I Oven. — Dryer —W.M.— ADDRESS with comply with such provisions.or this permit shall be Top FAU —W.H. — Q deemed revoked. Hood — Fan —Other— CITY -r��. L� j�Tel. N�SS 9 LICENSED CONTRACTORS DECLARATION LICENSE OR ,r/ 9 I hereby affirm that I am licensed under provisions of.Chapter 9 Disp. — Room Air Cond. REG. NUMBER 7"— Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR C SSED BY d and Professions Code,and my license is in full force and effect. y g ,� ' 'Size'&Type HP, KW, KVA, or KVAR li � � Q License.Num er / Classes Up to 1 Incl. FINAL U Contract ( �} '��' Over 1 to 10 Incl. DATE 2 SCh!1i VALIDATION 0 ❑ Over 10 to 50 Incl. FINAL ~ I am 4empt underec. Over 50 to 100 Inc. BY W W B.&P.C. for this reason Over 100 d Services, Swbd., MCC& Panelboards Date: D Z 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 HOME OWNER-BUILDER DECLARATIONTemp. Power Pole&Appurtenances ' Sign with One Branch Circuit F.;. I hereby affirm that I am exempt from the Contractor's License f :.:, Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits _ Professions Code): ❑ I, as owner of the property, will-do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). ' CONSTRUCTION LENDING AGENCYf_:V a" I hereby affirm that there is a construction lending agency for �� F the performance of the work for which'this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name3 ,' '_ PERMIT ISSUING FEE , - y 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 State laws regulating Electrical wiring, and hereby authorize representati of t my to enter upon a ve-mentioned rope fol i t' n purposes. 3 SEE REVERSE FOR EXPLANATORY LANGUAGE es gn ure of Permittee 7Date ��