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HomeMy Public PortalAbout9144 EMPEROR AVE_Electrical__ dvORKERS' COMPENSAUOFI DECLARATION ,20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that .I have a,certificate of consent t6 •self" Ce 80G insure, or a certificale 6f Workers'.Com(!bngotior*nsurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certif' d copy thereof (Sec. 3800, Lab. C.1 Policy No. ©O2 Company FOR APPLICANT TO FILL IN JOB ' ❑Certified copy is hereby furnished. New Residential Bldgs. PooI [ EACH NO. FEE ADDRESS ertified'copy is filed with the county buildin in ec- 1 & 2-Family, Sq. Ft. 6 a $ — $ '3V LOCALITY d G ti n de artment. Multi-family Sq. Ft. NEAREST CROSS" .��O Residential Swimming Pools OWNERS T. Date Applicant OR FIRM NAME LeWr l CERTIFICATE OF EXEMPTION FROM W RKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved First 20 ( P y Total No. CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Additional 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 so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HPPERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you-must forth- Oven — Dryer —W.M.— ADDRESS 15 with comply with such provisions or. this per shall be Top — FAU —W.H. — deemed revoked. CITY Tel. No. a Hood Fan —Other— LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that'I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER 5 Y'f Class. (commencing with Section 7000)of Division 3 df.the Business Power Apparatus& Large Appliances DISTRICT,& P ESSED d and Professions Code,and my license is in full force and effect. {�� O� _ Size &Type HP, KW, KVA, or KVAR cJ 0 Li n e Number33V 14 e Lic. Class Up to 1 Incl. FINAL U � ` 1� SL 6-Z 2,�►L .�,�� Over 1 to 10 Incl. DATE y Cl V VALIDATION cr Contrar Date Over 10 to 50 Incl. i � ❑ FINAL U I am exempt nder Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 aa- Services, Swbd., MCC& Panelboards ® U) Date: Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V El Over 1000 Amp. or Over 600 V Exemption for Reg. Ma nt. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATIO Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's Licensed I a� Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits aC 1 Professions Code): (" ❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors 11TE.- l:, structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— , (.ITH�". 15 1 � 2;0Business and Professions Code). _ CONSTRUCTION LENDING AGENCY CHECK. t^ ' I hereby affirm that.there is a construction lending agency for +_,HEsHG,Et ,_ -1 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 b® � Lender's Address r.�:.a 84 i:=r is r i f�I i ? a i I certify that I have read this application and state that The TOTAL FEE 3 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 mentioned oro erty r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S' nature o/rm ee Date ©s WORKERS' COMPENSATION DECLARATION. . 9oPw3ie7 APPLICATION FOR ELECTRICAL PERMIT O I her86y affirm That at I,have a certifice onSent;o self• 7CEA66806G insure,�ora certificate of Workers.' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certisfiieed^co y ther of (Sec. 3800, Lab Iy/ Pol•"y No! Company FOR APPLICANT TO FILL IN JOB % 1 l � hle Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS V g _ g LOCALITY - ❑Certified copy is filed with the c my building n ec- 1 & 2-Family, Sq. Ft. — tion de artm t. Multi-family Sq. Ft. CROSS NEAREST. Residential Swimming Pools Date Applicant `' -c OWNER OR /t J� FIRM NAME I •V CERTIFICATE OF EXEMPTION FOM WORKER MAIL \ Outlets: Rec Light Sw._ ADDRESS COMPENSATION IN RANCE This section need not be com lete if the work involved b First 20 CITY ( P Y Total No. Additional /I. ��• Tel. 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 so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS 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 Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M._ ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY Tel. No. 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 DISTRICT NO. O ,/ P ESSEDr BY >_ and Professions Code,and my license isin full force ar}d-Affect. Type X ! f Size &T e HP, KW, KVA, or KVAR D(UJ License NumberCL ��ic. Class S� Up to 1 Incl. FINAL lJ /ITU tyV 1 - $ Over 1 to 10 Incl. DATE /v/ VALIDATION CE ContractorI, Date Over 10 to 50 Incl. O ElFINAL I am exempt under Sec. Over 50 to 100 Inc. By U Over 100 / LUB.&P.C. for this reason n- Services, Swbd., MCC& Ponelboards , CD Date: 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 FAMILYemp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit , Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits41-_�:-- A Professions Code): ACCT. ea ❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors 3307 33.01, structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , I ITEM` Business and Professions Code). TOTALm �� CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for CHECK 33.013 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). CHANGE ani;l PLAN CHECKING FEE Lender's Name Lender's Address PERMIT ISSUING FEE 1311300-01301 11 ���1 `'*4! I certify that I have read this application and state that the TOTAL FEE Bill I AM11:5 above information is correct. I agree to mply with all County ordinances and State laws re atin lectrical wiring, and hereby authorize represents i oft i County to enter upon the ab e-mentioned grope f r in ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat"re of Permittee Date ©s