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Home My Public Portal About9132 EMPEROR AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT LJ = I hereby affirm that I have a certificate of consent to self insure, gr a certificate of Worker's Compensation Insurance, or tified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. C. •�q Policy NArt �. , Compa `� FOR APPLICANT TO FILL IN ADDRESS a JOB ❑ by 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. J Multi-family Sq.Ft. CROSS ST. Date / g f' Applicant hf�j•��!j/ �.'¢f� lQ Residential Swimming Pools ASSESSOR p MAP BOOK PAGE PARCEL OR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.ailk Light-,U—Sw. 6 FOIRM NAME COMPENSATION INSURANCE (YO 3rp FIfSt 20 MAIL (This section need not be completed if the work involved by the Total No. Additional • 7-O B-O ADDRESS permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures " First 20 APPLICANT Tot I No. Additional ? ADDRESS Date Applicant RE IDENTIA APPCES NOT OVER 3 HP. NOTICE TO.APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with suchPERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances j,-APPLICANT R 1�1-e LICENSED CONTRACTORS DECLARATION Size&&Typ�W,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 /' Ger 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and @ CITY LiP Tel.No. _ \ Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE bR Over 50 to 100 Incl. REG.NUMBER Class. 1t� d T� Lic.Class Over 100 DISTRICT NO. P SED BY Q License Number Services,Swbd.,MCC&Panelboards r/ Gle' � a Contractor �$i�� 4 Date-1-15--74 0-399 Amp.Under 600 V FINAL DATE ❑ 400-1000 Amp. Under 600 V _13 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 d I- 15A,or 20A, 120V,Lighting or Recept. Z Date: — 1 To t0 Branch Circuits Signature �� 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits _ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILYt f ' Temp.Power Pole&Appurtenances '�"( °v HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit =€ -=E.`•=5 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ? T' ""` Code): e FENS) a_) I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors s not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , i HEC and Professions Code). t _ CONSTRUCTION LENDING AGENCY CHANGE I hereby affirm that there is a construction lending agency for the 77 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) f(fGI�I_ytfl r 1127`9 Civ.C.) • ra PLAN CHECKING FEE {*3i 1' Lender's Namey� i{,c�uti �1/ 3 i)�FisaT: a _ ,/' PERMIT ISSUING FEE Lender's Address 9/J -9 e l" fit' � 4 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 p£ ordinances and State laws regulating Electrical wiring,and hereby authorize ` u✓ representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE X4lGqTe.R OF PER�E.E � - / ! o`DATE i DBS �SA 25M�rSETS �2-447r7� BUILDING � y� c MP IC!TION FOR PERy7411R'Q r J1EPAllAlVlEi�Jl OF ID lJ11.Oglal7 Al\dl a. SEn,uLE�E�.18C1`iH` S➢. IALiv1A 5L COUNTY OF LOS ANGELES WM. J. FOX CHIEF ENGINEER DISTRICT NO. GROUP ZONE PERMIT NO. U ADDRESS f RECEIVED BY READY FOR DATE ISSUED~ DU CITY TEL.NO. 3 COUNTY J i- FIRST INSPECTION W CERT.NO. .�_�� } EXPIRES 470 —� APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLYJOB - DESCRIPTION OF WORK ADDRESS D NUMBER OF OUTLETS ON CIRCUITS LOCALITY LOCATION BY ROOMS NEAREST LIGHT OUTLETS SW.I PLUGS FI%T CROSS ST. CIRCUIT A B C D E F G H m NAME / Z MAIL ADDRESS / O CITY TEL.NO. I AM THE' LEGAL POSSESSOR OF THE ABOVE LOS ANGELES COUNTY CERTIFICATE OF QUALIFICATION- 2V ELECTRICIAN. X17 -i ELECTRICIAN. I AM THE"GAL OWNER OF THE PROI EFRTY DESCRIBED ABOVE / n OWNER. CORRECTIONS J Q Z L7 1y O TOTAL ® 7 NO. OF OUTLETS $ APPROVALS NO. OF FIXTURES $ DATE INSPECTOR'S NAME NO. OF MOTORS H.P. $ CONDUIT NO. OF SIGNS TRANS. $ WIRING NO. OF RANGES OR HEATERS $ FIXTURES MISCELLANEOUS $ POWER i PERMIT FEE $ ✓ �.! UTILITY CO.NOTIFIED , TOTAL FEE i ` FINAL - "' DOS SA 11-46 APPLICATION FOR PERwr DEPARTMENT �F BUILDING AND SAFETY APPLICATION ELECTRIC COUNTY OF LOS ANGELES WM. J. FOX CHIEF ENGINEER NAME DISTRICT NO. 'GROUP, ZONE PERMIT NO. U ADDRESS <n E - 1 RECEIVED BY READY FOR DATE ISSUED U CITY �I t" TEL.NO. / FIRST INSPECTION / �1 Ij COUNTY CERT.NO. EXPIRES �� AP LICANT FILL IN HEAVILY®UTLINED PORTION ONLY JOB DESCRIPTION OF WORK. ADDRESS NUMBER OF OUTLETS ON CIRCUITS LOCALITY LOCATION BY ROOMS NEAREST LIGHT OUTLETS lsw. PLUGS 4FIXT CROSS ST. �1 CIRCUIT A B C D E F G H X NAME Z MAIL ADDRESS O CITY TEL.NO. 1 AM THE LEGAL POSSESSOR OF THE ABOVE LOS ANGELES COUNTY CERTIFICATE OF QUALIFICATION., ELECTRI IAN. I AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE OWNER. CORIiEMONS A J Q _Z 2 O TOTAL IT NO. OF OUTLETS APPROVALS NO. OF FIXTURES / $ DATE INSPECTOR'S NAM NO. OF MOTORS H.P. $ CONDUIT LNO. SIGNS TRANS. $ WIRING RANGES OR HEATERS $ FIXTURES LLANEOUS $ POWER FEE $ $ UTILITYCO.NOTIFIEDFEE F!NAL s mb wWORKERS'COMPENSATIONDECLARAT:lcaW . CE8612-8 ) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES B SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) ( �2�, FOR APPLICANT TO FILL IN ,JOB Policy No. Company EACH NO. FEE ADDRESS New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY OMulti-family'Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME Datz Applicant Outlets: Rec._Light Sw. MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE PLAN CHECK d APPLICANT p (This section need not be completed if the work involved L by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First Total No. Additional �ADDRESS U onal I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0 permit is issued, I shall not employ any person in any manner PERMIT U so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT 0.W Oven Dryer_W.M._ ADDRESS Date Applicant Top ' FAU _W.H.. Hood Fan --Other— CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICEN 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. PRES D BY with comply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR deemed revoked. l� Up to 1 Incl.' FINAL Over 1 to 10 Incl. DATE _�/(7r?� VA' DATI. LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. CCJ/ I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 —r 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 DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit / License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): Misc:Conduits&Conductors z 5 1 1,2 A 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 0 0 o o 2 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 2 0. 0 1 9,50 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) o l0 a 1 9, 5 0 F issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0 &Q 5—8 1 Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE F 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. � cc SEE'REVERSE FOR EXPLANATORY LANGUAGE J l " 2 D / . Signature of Permittee Efate