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Home My Public Portal About5616 GOLDEN WEST AVE_Electrical__ "d WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 76A663 hAreby affirm that J have a certificate of consent to self insure, or a certiPcate 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 ��n�� i�„m. ❑ ADDRESS D Certified copy is hereby furnished. New Residential Bld s.&Pools NO. EACH FEE Bldgs. LOCALITY,/ / n i]7 Q ❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. — $ $ �� A✓ �' r, 6 department. Multi-family Sq.Ft. NEAREST department. J' Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Cutlets:Rec._Light Sw. OWNER OR S ` Qt1/ �,!l COMPENSATION INSURANCEFIRM First 20 � (This section need not be completed if the work involved by the MAIL � J � permit is for one hundred dollars($100)or less.) Total No. Additional .r �.7 4 I certify that in the performance of the work for which this permit CITY f ; Tel. o. 1 i is issued, I shall not employ any person in any manner so as to PLAN become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT K 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. provisions of the Labor Code, you must forthwith comply with such PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 100��.� 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. (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. >_flEG.NUMBBER Over 50 t0 100 Ind. LICENSE Class. 12- Over 100 DISTRICT NO. PPO ESSED BY O License Number Lic.Class p U Services,Swbd.,MCC&Panelboards ep � j cc 0-399 Amp.Under 600 V FINAL O Contractor Date DATE ) rJ /��3 El am exempt under Sec. 400-1000 Amp.Under 600 V / L. VALIDATION W Over 1000 Amp.or Over 600 V FINAL y 11 B.&P.C.for this reason BRANCH CIRCUIT FEES BY /� _ W Date: 15A,or 20A, 120V,Lighting or Recept. Gt 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances y HOME OWNER-BUILDER DECLARATION AL•Z' =# I 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 •F�,fsf 27, 2'Lr Code): q I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEMS Et t is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 236 9 25 and Professions Code). f y- i•HE-Sl i•Jtif as:•_ CONSTRUCTION LENDING AGENCY tt��qq�[�,�3 t'- •t 1 hereby affirm that there is a construction lending agency for the '_•t-tl^INGE ,Iji3 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) Lender's NamPLAN CHECKING FEE e - 00100-000 Z 5/117 9:3, PERMIT ISSUING FEEfs�a 1 FN, 9 412 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 fo 'nspection purpos si SEE REVERSE FOR EXPLANATORY LANGUAGE �l 14, y SI -TURE F PERMITTEE- DATE ;!,; that I S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that have a certificate of consent to self insure, 76A663 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 ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ❑ 1 &2-Family,Sq.Ft. — $ $ LOCALITY �I r Certified copy is filed with the county building inspection _ NEAREST �/ department. Multi-family Sq. Ft. CROSS ST. I V C Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR NAME (� COMPENSATION INSURANCE First 20 FIRM (This section need not be completed if the work involved by the MAILS 3 At �� '� permit is for one hundred dollars($100)or less.) Total No. Additional I certify that in the performance of the work for which this permit CITY _ T is issued, I shall not employ any person in any manner so as 4o 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 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 PERMIT1�7��J provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 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. (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. Professions Code, and my license is in full force and effect. Over 10 to 50 1 cl. } Over 50 to 100 Incl. LICENSE Cl REG.NUMBB ER ass. a- License Number Lio Class Over 100 DISTRICT NO. p PyYO�WSSED BY 0 Services,Swbd.,MCC&Panelboards Contractor Date 0-399 Amp.Under 600 V.. DATE O 400-1000 Amp.Under 600 V +� j !i 1 VALIDATION U ❑ 1 am exempt under Sec. L J` W Over 1000 Amp.or Over 600 V FINAL //// (L B.&P.C.for this reason BRANCH CIRCUIT FEES BY cam/ U) Date: 15A,or 20A,120V,Lighting or Recept. ` J Z 1 To 10 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 FAMILY Temp.Power Pole&Appurtenances 2 HOME OWNER-BUILDER DECLARATION q g I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit i9€;CTAI for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits .,�('yy:, Code): 1330 at 63.to ❑ 1, as owner of the property, will do the work and the structure Misc.Conduits&Conductors 1 ITEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) y- 60 63 m 60 and Professions Code). TOTAL AL 9� CONSTRUCTION LENDING AGENCY CHECK 63.6'D 1 hereby affirm that there is a construction lending agency for the CHANGE .00 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) ti Civ. C.) PLAN CHECKING FEE Lender's Name � i - I�:I�Ji 1117/9 PERMIT ISSUING FEE Lender's Address „ 6546 1 :47 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 Cou to enter upon the above-mentioned property fo In ection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE "51 ATURE PERMITTEE DATE