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Home My Public Portal About5438 ENCINITA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76- 10/$1 APPLICATION FOR ELECTRICAL PERMIT {� I hereby affirm that I have a certificate of consent to self insure, CE-806G LJ or a.certificate,of WoSkers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof (Se/c.3800,Lab. C.)• Policy NO�� /-03 Company' FOR APPLICANT TO FILL IN JOB %_ ❑ Certified o r-by furnished. New Residential Bldgs.& Pools , EACH NO. FEE ADDRESS � 1 & 2-Family, Sq.Ft., �// — $ LOCALITY ❑-Certified copy is filed with the-county building inspection — departme t. Multi-family Sq. Ft. tJ�� NEAREST CROSS ST. Date C Applicant Residential Swimming POOIS OWNER NAME / CERTIFICA OF EXEMPTION FROM WORKERS'" Outlets:Rec— Light Sw. — MAIL COMPENSATION INSURANCE ADDRESS completed if the work involved by the First 20 (This section need not be com p Total No. Additional CITY Tel.No. permit is for one hundred dollars($100)or less.) PLAN CHECK I certify that in the performance of the work for which this permit APPLICANT 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 NOTICE TO APPLICANT: If, after making this Certificate of PERMIT Exemption,.you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT, provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS _7" � provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _ CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. — Room Air Cond. Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER' �OD 93/ Professions Code,and my license is in full force and effect. DISTRICT NO. P O sSED By Power Apparatus& Large Appliances a� Size& Type HP, KW,KVA,or KVAR �� z License Number 4 !>3 1 Lic.Class Up to 1 Inc]. FINAL Over 1 to 10 Incl. DATE / VALIDATION Q Contracfo>�2�-'� Date Over 10 to 50 Incl. l ❑ FINAL U I am exempt under Sec. Over 50 to 1,00 Inc. BY Ld BAP.C.for this reason-' Over 100 Services,Swbd.,MCC& Panelboards Date: 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 Temp.Power Pole& Appurtenances 2 HOME OWNER-BUILDER DECLARATIONn I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit AfGT° r for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3 85.27 Code): 07 1� E] 1, Misc. Conduits & Conductors 1 ITEMS I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL , 80-5 o 2 d`' and Professions Code). CHECK $5°27 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the , CHANGE performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ. C.). PLAN CHECKING FEE 0000-0001 12/ 7/95 Lender's Name PERMIT ISSUING FEE �7 3645 1 AM10*-21 Lender's Address I certify that I have read this application and state that the above TOTAL FEE 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE >tI6 ig ature of rmit e Date WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate (5f Worker's Compensation Insurance; or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.y3800 Lab. C.) Policy No. 229-93 L7Cllt Company Sta e fl)50 1 FOR APPLICANT TO FILL IN JOB X /� ADDRESS 5Y-2„38 irU L�'c��2il.1.a A�.�T'.C.. ❑ CertQQwp is hereby furnished. New Residential Bldgs.&Pools NO.1 EACH FEE LOCALITY ® Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. �a3' $ $ PY Y 9 P NEAREST tw department. Multi-family Sq.Ft. CROSS ST. Date 5-16-9 Applicant JWa3si IA Residential Swimming Pools ASSESSOR / MAP BOOK ��d" PAGE�/ PARCEL L9 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.fP Light GL Sw. T FFIWNER OR IRM NAME— - COMPENSATION INSURANCE First / MAIL �V'i (This section need not be completed if the work involved by the ADDRESS �7CX) Ml�� C1V? permit is for one hundred dollars($100)or less.) Total ditional a.1 I certify that in the performance of the work for which this permit CITYC01� Cit i Tel. 55a-172 7 is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtu 1 Firs APPLICANT Jc'gt�_-4C3 I' Tota Additiona ADDRESS 4700 fi,Iuer T)Y-iye Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. 1. NOTICE TO APPLICANT: If, after making this Certificate of CITY `TE3• X e ci.� TeFp pZ 1�7 y Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP. _.l/ 2 p rovisions of the Labor Code, you must forthwith complywith such PERMIT APPLICANT Je`3�� I,1- provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or,KVAR ADDRESS 4703 �-?�r. 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 , , ,__.. 'Vqld 22.7 Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 Incl. RIEG NSE OR NUMBER `.A/ 1=�.'*.,- Class a Over 100 DISTRICT NO. PROCES Y 0 License Number ��31 Lic.Class R Services,Swbd.,MCC&Panelboards FINAL Contractor 1 1` - '1� 'Y J� Ii)C' Date 5-16-.95 0-399 Amp.Under 600 V DATE 0 ❑ 400-1000 Amp.Under 600 V ��Z— ,'� I am exempt under Sec. VALIDATION V Over.1000 Amp.or Over 600 V FINAL W B.&P.C.for this reasona. BRANCH CIRCUIT FEES BY f Date: 5--16--9 15A,or 20A, 120V,Lighting or Recept. C/�Y _J Z 1 To 10 Branch Circuits Signature 9 �_ 11 To 40 Branch Circuits 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 I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit M T W for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Cade) _ -n ❑ 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) r_a and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the ; I _.?. 1_ performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) m Z '•5+- W n_r 1• Civ. C.) PLAN CHECKING FEE Lender's Name , PERMIT ISSUING FEE 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 5-16-0 \�OF PERMITTEE —~ DATE hh�..