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HomeMy Public PortalAbout9842 FLAHERTY ST_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-9t) APPLICATION FOR ELECTRICAL PERMIT I he y affirm that I have aIcertificate of consent to self insure, , or a rtificate-of Worker's Compensation Insurance, or a certified' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. COPY r76A663 eof(Spec. 3800 Lab C)• / ` Policy No Z Z )•�51 3 /qCompany SI A,-c 'y,✓. FOR APPLICANT TO FILL IN JOB ADDRESS - I�WV••riI Certified copy is hereby furnished - ` New Residential Bldgs &Pools NO EACH FEE ❑ _ $ $ LOCALITY 'Certified copyis filed with the county'building*inspection 1 &2-Family,Sq.Ft department Multi-family Sq. Ft. CROSS ST Date 7 14�q5,' Applicant Egz;A='l, Residential Swimming Pools ASSESSOR v MAP BOOK O�' PAGE I��`� PARCEL e5i;�?- CERTIFICATE OF EXEMPTION'FROM FROM WORKERS' Outlets.Rec _Light Sw OWNER OR COMPENSATION INRANCE', First 20 FIRM NAME (This,section need not be completed if the work involved by the MAIL permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS I.cerfify that in the performance of'the work for which this permit CITY, _ No is issued, I shall not employ'any,-person many manner so 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 ARPLICANT.•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.forthwrth'comply with Such ERMIT provisions or this permit shall be deemed revoked r'• Power Apparatus&Large Appliances APPLICANT` L�}�� Z)�.te.. LICENSED`CONTRACTORS DECLARATION Size.&Type HP,KW,KVA,or KVAR ADDRESS "�l f h/ I hereby affirm that I'am'"licensed under'provisions of'Chapter 9 Over 3to10Incl- '&/I (commencingwith Section7000) of Division'3 of•tKe Business and CITY L(�'r Tel No ZV3'Zy� Professions Code, and my.hcense is in full force and effect: Over'10 to 50 Incl SE OR Over 50 to 100 Ind. REG NNUM ER •S��S 7 Class } -13 IJ 2 Q y V Over 100 DISTRICT NO PR SED BY Q License Number Lic Class /� p Services,Swbd.,MCC&Panelboards Contractor V rK�RA Date -1• I 0-399 Amp Under 600 V FINAL DATE ^• _ - ❑ 400-1000 Amp.Under 600 V �?^ (j VALIDATION. V I am exempt under Sec. Over 1000 Amp or Over 600 V FINAL W B&P:C for this reason BRANCH CIRCUIT FEES BY Date.' 15A,or 20A,120V,Lighting or Recept _ Z 1 To 10 Branch Circuits Sianatur ( 11 To 40 Branch Circuits 41 Or More Branch Circuits ❑ Exemption for Reg Mamt.Elect. 15A,20A,208V To 277V Lighting Br.Circuits y SINGLE FAMILY Temp Power Pole&Appurtenancesnr• a. HOME OWNER-BUILDER DECLARATIONL with One Branch Circuit _ I hereby affirm that I am exempt from the Contractor's License Law Si for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits- Code): ircuits Code): FTC EJI, 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) TOTAL 6 d �65 and Professions Code). CHECK - L v i c, CONSTRUCTION LENDING AGENCYh#tat. i �' "- • _.. - - ,€_ii • . I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) / Civ C.) PLAN CHECKING FEE Lender's Name©W IJP 12" til ih d h1`#10jn1�1 PERMIT ISSUING FEE Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE 4 ill— 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 ) Amsp purposes SEE REVERSE FOR EXPLANATORY LANGUAGE PER EE DATE " WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 76A663 I h'ereby"affitm that.l have a certificate of'consent to self Insure, ora 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 3 / Company' `STI}TE FV t FOR APPLICANT TO FILL IN JOB � ADDRESS 'T Certified copy is'hereby'furnished New Residential Bldgs.&Poo NO EACH FEE ., p LOCALITY ❑ • :Certified co is-filed-with the count building Ins ection 1 &2-Family,Sq.Ft 7 — $ $ PY Y 9 NEAREST department. /� Multi-family Sq. Ft. CROSS ST Date"- �– '93 Applican </ Residential, Pools , AssessOR /J MAP BOOK �� PAGE `/�j"� PARCEL !//� �� CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR ` COMPENSATION INSURANCE Outlets Rec _Light Sw FIRM NAME (This section need not be completed if the work involved by the First 20 MAIL y Ip ADDRESS 7 permit is for one hundred dollars($1Total No Additional 00)or less.)- � , I certify that in the performance of the work for which this permit CITY T I No. is Issued,-I shall not employ ariy person in any manner so as to / become subject to the Workers' Compensation Laws Lighting Fixtures First 20 PLAN CHECK J p 9 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVERS 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 /��� provisions'or this permit shall'be deemed Irevokad Power Apparatus&Large Appliances APPLICANT 4 J LICENSED CONTRACTORS-DECLARATION • Size&Type HP,KW,KVA,or KVAR ADDRESS n I hereby affirm.that I am licensed tinder provisions of Chapter 9 7� 5� L. L�OAC (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl. V, IZ ! q L�e✓ ��/ Tel No'. Y3–Zy5i3 Professions Code, and my license is in full force and effect Over 10 to 50 Incl LICENSEOR 7 u �J } �7 `' T 2 Over 50 t0 100 IDREG.NUMBER ,�(�0 Class �7 0. License Number 13L J 9y LiC Class /J Over 100 DISTRICT NO- j� P O SSED BY O Services,Swbd,MCC&Panelboards Contractor%%«Lf7?+`�'L' Date —�y^9� 0-399 Amp.Under 600 V FINAL DATE _ ET I am exempt under Sec 400-1000 Amp.Under 600 V W Over 1000 Amp.or Over 600 V FINAL /� VALIDATION B&P C for this reason BRANCH CIRCUIT FEES BY / Z Date: 15A,or 20A, 120V,Lighting or Recept _ Signature _ Q�Ls� C�l a 1 To 10 Branch Circuits 11 To 40 Branch Circuits El 41 Or More Branch Circuits Exemption for"Reg Maint Elect 15A,20A,208V To 277V Lighting Br Circuits 7 L SINGLE FAMILY Temp.Power Pole&Appurtenances y HOME OWNER-BUILDER,DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit t _' for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3 30:3 ' L1a.` Code) — — ❑ 1 ITR I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors3 }� is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 1{�{AL ,� and Professions Code -CHECK'I-. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending,agency for the t'�j��•f fir' `Lt!j performance of the work for which this permit•is issued (Sec 3097, PERMIT FEE (Sub-Total) Civ. C.) Lender's Name PLAN CHECKING FEE ?!'iC t! Ded.✓L�-� – PERMIT ISSUING FEE p?�p [{1 !5 j Ak 10'.11 Lender's Address i �- I certify that I have read this application and under penalty of purlury state TOTAL FEE r Q 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 inspec purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 93 NATURE OF RMITTEE DATE