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Home My Public Portal About4901 FIESTA AVE_Electrical__ 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.,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 0 ADDRESS 1 rn roe Certified copy is hereby furnished, New Residential Bldgs.&Pools NO. EACH FEE LOCALITY EJ 1&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 AssESSOR ,,.,��yy�r MAP BOOK PAGEG.s9L' PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.-1 —LightNER Sw. FOIP.M NAME r .+ COMPENSATION INSURANCE ��W Q `-^+ First 20 MAIL (This section need not be completed if the work involved by the Total No.� Additional ADDRESS 0 AJ permit is for one hundred dollars($100)or less.) I certify that in the performance of.the work for which this permit CITY C4 r�rTel.No. /1 60-7` is issued, I shall not employ any person in any manner so as to PLAN CHECK 4 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. rovisions of the Labor Code, you must forthwith comply with such PERMIT P y P y APPLICANT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. iG a (commencing with Section 7000) of Division 3 of the Business and CITY L _A No. vb Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE B � ' Class. } i`. /A Q� Over 50 t0 100 Incl. REG.NUMBER a License Number -/S/ V Lic.Class .Y Over 100 DISTRICT NO. PROCESSED BY Services,Swbd.,MCC&Panelboards f ///�� 140-3-1-74 0-399 Amp.Under 600 V FINAL p Contractor { I /l./) t//1�) • DateDATE 7 F-1I am exempt under Sec. 400-1000 Amp. Under 600 V .-23_g VALIDATION w Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY d Date: 2~1/~ X 15A,or 20A, 120V,Lighting or Recept. Z_ 1 To 10 Branch Circuits Signature i 1 To 40 Branch Circuits F141 Or More Branch Circuits Exemption for Reg. Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits d SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION IF forI 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 307 94 65 Code): ...........__...__....._. .. .. ..d C it d Conus&Conductors -f' ht. I, as owner of the property, will do the work and the structure Misc. _... .. __.........._ 1 ITEMS . f'' is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 9.4 - 65 and Professions Code). ......_ ...._................._..... ... . CHECK 94.6551 CONSTRUCTION LENDING AGENCY - - rs�A�`* I hereby affirm that there is a construction lending agency for the CHANGE E i performance of the work for which this permit is issued Sec. 3097, p p ( PERMIT FEE (Sub-Total) Cry Civ.C.) PLAN CHECKING FEE 0000--0001 2!17/933 Lender's Name PERMIT ISSUING FEE 8251 r�'M *2-101 C0 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 SIGNATURE OF PERMITTEE DATE WORKERS' COMPENSATION DECLARATION '°'B' APPLICATION FOR ELECTRICAL PERMIT I hereby affirm CE 806G-that I have a certificate of consent to self 7� insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY Iu' or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH PNO. FEE ADDRESS � 01 �I�/'/ Certified copy is filed with the county building inspec- y, q. LOCALITY {1 8 2-Famil S Ft. $ $ J G tion department. Multi-family Sq. Ft. NEAREST ` �., D Residential Swimming Pools CROSS ST. 49V�1661�,,ki/ �� Date Applicant FFIIRM NAMEWNER OR /`!V N� l��L CERTIFICATE OF EXEMPTION FROM WORKERS' OutMAIL lets: Rec Light Sw._ � COMPENSATION INSURANCE 20 ADDRESS T O��•f'/ This section need not be completed if the work involved b First ti ( P y Total No. Additional CITY �, Tel. No. the permit is for one hundred dollars ($100)or less.) ' I certifythat in the performance of the work for which this PLAN CHECK p APPLICANT permit is i sue I shall not employ any er'on in any nner so as to co a subject to the Worker Compensate n Laws. ghting Fixtures First 20 ADDRESS lDh t Total No. Additional QJ/V {� CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE T APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater_D.W. — Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS 716 5• W1 W.- with with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. CITY � 44— Tel. No.C1411 70(7 LICENSED CONTRACTORS DECLARATION Hood Fan _Other_ Dis _ Room Air Cond. LICENSE OR l ,,,•t I hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBER J \5-6 0� Class.C—/V (commencing with Section 7000) of Division 3 of the Business DISTRICT NO._ PROCESSED$Y and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances /��/ d• //�� C. f^ Size &Type HP, KW, KVA, or KVAR' 01 V 1®( License Number V(lJ Lic. Class /'V Up to 1 Inc[. FINAL � 7/(` 4!DContractor Dote r�� Over 1 to 10 Incl. DATE v VALI ATION 0 FIN Over 10 to 50 Incl. ILI ❑ I aALm exempt under Sec. Over 50 to 100 Inc. BY d' B.&P.C. for this reason Over 100 Z S17*ces0 , Sw MCC& Panelboards „ / �0 a z Date: _20 mp. Under 600 V t/1! Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. 4 9 9.6 A SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 0 0 0 0 0 2. 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits I o - 25-50 Professions Code): 'o ? o25505 Misc. Conduits &Conductors I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , :0 '. 1 0-- 86 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 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 Lender's Address I certify that I have read this application and state that the TOTAL FEE S above information is correct. I agree to comply with all County ordinances and State lawsreg lating Electrical wiring, and hereby authori a represent s of this County to enter upon the abo a-m boned pro y for inspection urpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE 0 Signature of Permittee Date