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Home My Public Portal About5819 GOLDEN WEST AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT 76A66 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. CompanyFOR APPLICANT TO FILL IN JOB U/ -' Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ADDRESS 09 $ $ LOCALITY ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. DateApplicant Residential Sing P o ASSESSOR �� MAP BOOK PAGE C�" PARCEL O CERTIFICATE OF EXEMPTION FROM WORKERS' g j _� NER OR COMPENSATION INSURANCE Outlets:Rea Light Sw. ` IRM NAME e� First 20 J MAIL (This section need not be completed if the work involved by the � ADDRESS 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 T I.No. _�U.y�V is issued, I shall not employ any person in any manner so as to C� become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 PLAN CHECK J p 9 / APPLICANT tal No. Additional ADDRESS Date Applicant RE,St�ENT AL APPLI NC OT 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 APPLIANCE OT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such P RMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances PPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS C) 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" I� )1Tel. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSEOROR 01>_r Over 50 to 100 Incl. REG.NUMBER Class. 13, O License Number Lic.Class C3 Over DISTRICT NO. R SSED BY 0 _ Services,Swbd.,MCC&Panelboards � P fl Contractor Date_� 0-399 Amp.Under 600 V FINAL DATE ,, O ❑ I am exempt der Sec. 400-1000 Amp.Under 600 V � '� W Over 1000 Amp.or Over 600 V FINAL VALIDATION a B.&P.C.for this reason BRANCH CIRCUIT FEES BY U) Date: 15A,or 20A, 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El 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 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law g ;-;'•C" n for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits '6. r 0 Code): _ _ il z v=s ElMisc.Conduits&Conductors. TTCI-I I,as owner of the property,will do the work and the structure 1 s_.t= is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , _`, � � se and Professions Code). - CONSTRUCTION LENDING AGENCY CHEC7; �_)� I hereby affirm that there is a construction lending agency for the _ ,CIO performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) • Civ. C.) PLAN CHECKING FEE _ c./-_rf5 19 Lender's Name ?' f_113-001-01 J r _r, s PERMIT ISSUING FEE 3343 Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE A�, 00 N2 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 NATURE PERMITTE DATE 'rm tli t I COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 76A663 I laereby affirm Haat I have a Certificate of consent to self insure, or a certificate of W-orker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy Preof(Sec.3&00 Lab. C.) _ y _ _ Policy NO. Company FOR APPLICANT TO FILL IN JOB / ADDRESS C0( Certified co Is hereby furnished. ]NO. EACH FEEPY Y New Residential Bldgs.&PoolsLOCALITY ❑ 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 PAGE MAP BOOK PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. FWNER OR PM NAME COMPENSATION INSURANCE First 20 �('� j (This section need not be completed if the work involved by the MAIL tADDRESS d �[p� 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 '` Tel.No. i� is issued, I shall not employ any person in any manner so as to PLAN CHECK Q 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 PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT of—,Z,, E' LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR f� 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. LICENSOR E Over 50 t0 100 Incl. REG.NUMBER } BER d Over 100 DISTRICT NO. PR C D BY Q License Number Lic.Class �Q 1 C�s�i� %Services,Swbd.,MCC&Panelboards cc Contractor Date 0-399 Amp.Under 600 V FINAL O DATE El I am exempt under Sec. 400-1000 Amp.Under 600 V VALIDATION U Over 1000 Amp.or Over 600 VFINAL a B.&P.C.for this reasonBRANCH CIRCUIT FEES BY Date: 15A,or 20A,120V,Lighting or Recept. 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 HOME OWNER-BUILDER DECLARATION t �-••.� ith One Branch Circuit w 1 hereby affirm that I am exempt from the Contractor's License Law Sign ;`r for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits CH V 4., __ Code): ;, r,3 `.. .. . oI 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) and Professions Code). 1;_I13 i— jj jU CONSTRUCTION LENDING AGENCY 25 Z_ a ° 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 PERMIT ISSUING FEE rx l0 Q 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 urposes SEE REVERSE FOR EXPLANATORY LANGUAGE v NATURE OF MITTEE — DATE