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HomeMy Public PortalAbout9129 EMPEROR AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a.certificate of consent to self insure, 76A663 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.) FOR APPLICANT TO FILL IN l.�rr ,���/" •�' Policy No. Company ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY $ $Ft Sq. . _ Certified copy is filed with the county building inspection 1 &2-Family, NEAREST . department. Multi-family Sq.Ft. CROSS ST. o6i te'l "ol Residential Swimming Pools .ASSESSOR Date AppllCan %MAP BOOK I PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS Outlets:Rec.J&Light S FFIIRM WNER NAME COMPENSATION INSURANCE First 20 (This section need not be completed if the work involved by the 1— ADDRESS e�n �'��r permit is for one hundred dollars($100)or less.) Total No. Additional q I certify that in the performance of the work for which this permit CITY Tel.NoZ is issued, I shall not employ any person in any manner so as to 4 PLAN CHECK / become subject to the Workers' Compens tion Laws. Lighting Fixtures First 20 APPLICANT f Total No. Additional ADDRESS n , a Date ^Z — Appli °" RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO AP (CANT- f, after aking this tificate of CITY Tel.N Exemption, you should be me subjec to the Workers ompensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor C you ust forthwith comply with such PERMIT p Y P Y APPLICANT provisions or this permit s<hall deemed revoked. Power Apparatus&Large Appliances D LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS -T, C- I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 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 Incl. LICENSE OR d Class Over 50 to 100 Incl. REG.NUMBER . Over 100 DISTRICT NO. PR D B O License Number Lic.Class Services,Swbd.,MCC&Panelb d 06 _ Q Contractor Date 0-399 Amp.Under 600 V DATE �} O El -1000 Amp.Under 600 V �t�l� l3 V I am exempt under Sec. VALIDATION W Over 1000 Amp.or Over 600 V FINAL 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 El 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&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): )JaJ 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) and Professions Code). A�,-.� g CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 3307. } performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) + <J a7 C%. -"' rj '' Civ.C.) , al mITEMS. PLAN CHECKING FEE C,•! �'"' �+ Lender's Name r "r r TtFfAQ,- : -S�.P�m 90 PERMIT ISSUING FEE 2J� LlCC 5 Lender's Address Q t-+. l,F4E�!', �,4 0�r I certify that I have read this application and under penalty of purjury state TOTAL FEE 1 Q F that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize xy 41- . representatives of this County to enter upon the above-mentioned propertyij )orspectionpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE co ��.:j -ZATURE OF PERMITTEE DATE '~� WORKEF?'S COMPENSATION DECLARATION 720-0019 6A663 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 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(Sec.3800 Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS ��C Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE El $ $Ft Sq. . LOCALITY — Certified copy is filed with the county building inspection 1&2-Family, — NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR d .2 �y PAGE Q�h PARCELQ�d" CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. /OWNER P.M NAMS�� COMPENSATION INSURANCE 7 ) (This section need not be completed First 20 MAIL 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.N 7 /3GQ is issued, I shall not employ any person in any manner s0 as t0 PLAN 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 p y Power Apparatus&Large Appliances APPLICAN provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA +ryCgR ADORES I hereby affirm that I am licensed under provisions of Chapter 9 Over 0 O ncl.. (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 Incl. LICENSE OR Over 50 t0 100 Incl. REG.NUMBER Class. d Over 100 DISTRICT NO. PR C ED BY Q License Number Lia Class U Services,Swbd.,MCC&Panelboards O �7�s�� Q FINAL Contractor Date 0-399 Amp.Under 600 V DATE t �-1 3 VALIDATION V 0 400-1000 Amp.Under 600 V El I am exempt under Sec. 4 Over 1000 Amp.or Over 600 V FINAL W B.&P.C.for this reason BRANCH CIRCUIT FEES BY G_" d 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,208V To 277V Lighting Br.Circuits i SINGLE FAMILY Temp.Power Pole&Appurtenances _ HOME OWNER-BUILDER DECLARATION i•�1.: a'6• I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 330 43--,-'- --,-'- Code): tt Fq r H; t d &C it d Conus onucors i t tf fti- I,as owner of the property,will do the work and the structure Misc. is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 43 m +'0 and Professions Code). CHECK 'it 4.3 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 'CHANGE .00 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.G.) PLAN CHECKING FEE 0000-000 1 5/17/9", Lender's Name PERMIT ISSUING FEE ;t 42 1 AM 9:07 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 insp tion purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE {s_^, ov SIG NIy UR OF PERMITTEE („) DAA' 'Wfirm that :,COMPENSATION IhaacerDECLARATION zo-ootvDPW 3ia7 APPLICATION FOR ELECTRICAL PERMIT I hereby'dffirm that I have a certificate of consent to self ' ..ce eo insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a 4ertified copy thereof(Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB r,, t, ❑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 LE tion department. Multi-family Sq.'Ft. — NEAREST CROSS ST. Residential Swimming Pools Date Applicant OWNER FIRM NAME ' / CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light '>' Sw. MAIL Pp t/t COMPENSATION INSURANCE First 20 ADDRESS pC 9 EM(This section need not be completed if the work involved by Total No. Additional CITY f LC el. No the permit is for one hundred dollars ($100)or less.) 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 Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Co pens ation Laws. Total No. Additional CITY Tel. No. Date � Z7� Applicant ` Fixed Appliances of Over 1 HP PERMIT NOTICE TO APPLICANT: If, after akin this Certificate of / APPLICATION Exemption, you should become subject to the Workers' Range J— Heater—D.W. J_ Compensation provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS �,', ��!G/• with comply with such provisions or this permit shall be Top FAU W.H. — p deemed revoked. Hood - Fan Other— CITY --K o_ e(-,\ Tel. No. t0• %o is 3 LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp' —Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRI T O. PR SSED Y >- and Professions Code,and my ice is in full force and effect. i Size&Type HP, KW, KVA, or KVAR Q License Number Lic. Class Up to 1 Incl. FINAL C) Over 1 to 10 Incl. DATE _ C \ VALIDATION CO Contractor Date Over 10 to 50 Incl. F1SINAL I am eimpt under Sec. Over 50 to 100 Inc. BY t LU B.&P.C. for this reason Over 100 (W-AL-441 a Date: Z Z Z` Services, Swbd., MCC& Panelboards Z 0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V E] Over 1000 Amp. or Over 600 V Exemption f Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances 2 HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ACCTo g Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): �i,:t(.I7 ji'.1.oLl:l Ell, as owner of the property, will do the work and the Other Conduits& Conductors i Ell structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— poll. TUBAL Business and Professions Code). 42- 00 CONSTRUCTION LENDING AGENCY CHECK 401.;1! I hereby affirm that there is a construction lending agency for GHA UE 1111 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). - Lender's Name PLAN CHECKING FEE �0000-0001iz'±8-1f 90 PERMIT ISSUING FEE 9191 1 AN 9, Lender's Address `4=' I certify that I have read this application and state that the TOTAL FEE O� 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 *above-ment' ned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f Permittee Date ©s