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Home My Public Portal About4820 HALLOWELL AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0079 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a'-certificate of consent to self insure, 76A663 or a•certificatfa'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.) o Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE$ $Ft Sq. . LOCALITY _Certified copy is filed with the county building inspection 1 &2-Family, NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASS SSOK PAGE IgARCEL, CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR e r� COMPENSATION INSURANCE g FIRM NAME C G({ +f First 20 MAIL (This section need not be completed if the work involved by theTotal No. Additional ADDRESS permit is for one hundred dollars($100)or less.) 1 certify that in the performance of the work for which this permit CITY Tel.No.�//� is issued, I shall not employ any person in any manner so as to PLAN CHECK �t 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 com with such PERMIT p I p y 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 Incl. a LICENSE Over 50 t0 100 Incl. REG,NUMBER Class.ER O License Number LIC.Class Over 100 DISTRICT NO. �� P SSE BY 0 Services,Swbd.,MCC&Panelboards Cc F NAL Contractor Date 0-399 Amp.Under 600 V❑ DATE 0 400-1000 Amp.Under 600 V I am exempt under Sec. VALIDATION w Over 1000 Amp.or Over 600 V FINAL a. B.&P.C.for this reason BRAU94,rSIRCI F BY (n Date: o A, lghJngRecept. Z 1To nch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Li More Branch Circuits (,,,y(DExemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp. Power Pole&Appurtenances X HOME OWNER-BUILDER DECLARATION ( •L•i us 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 ==''.!• o'�- X CCode): I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors _s not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ' l t_f i AL �-y 42 _ -+0 and Professions Code). �: L,• 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 (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) PLAN CHECKING FEE _{s!i ii L; I: 1 -7 Lender's Name PERMIT ISSUING FEE '710 :F 13 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 reg ating Electrical wiring,and hereby authorize represen t' es of this o to enter upon the above-mentioned property for in Jon p 0 SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF R 1 E ` DATE WORKERS'COMPENSATION DECLARATION CE-806G-663 10/81 APPLICATION FOR ELECTRICAL PERMIT 1, ie y efm thaf�I have a certificate of consent to self insure, or a c .n cafe of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy tt eof(Sec.3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ig It� Certified copy is hereby furnished. New Residential Bldgs.& Poo EACH NO. FEE ADDRESS �y r/ /y ❑ 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY-�� Certified copy is filed with the county building inspection NEAREST department. Multi-fa I SQQ��Ft Resider A6*1 Y4 t0111 CROSS Date Applicant OWNER O OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light — Sw. — MAIL _ /J COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved by the First 20 ( Total No. Additional CITY Tel.No. permit is for one hundred dollars($100)or less.) PLAN CFfECK_ 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' Compensataws. Lighting Fixtures First 20 ADDRESS f Total No. Additional 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 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 9Disp. Room Air Cond. REG.NUMBER Class.LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED Power Apparatus& Large Appliances Size & Type HP,KW,KVA,or KVAR • O License Number Lic.Class Up to 1 Incl. FINAL V Over 1 to 10 Incl. DATE VALI ION tx Contractor Date❑ Over 10 to 50 Incl U FINAL I am exempt under Sec. Over 50 to 100 Inc. BY � Over 100 A- B.&P.C. for this reason N Services,Swbd.,MCC& Panelboards ® Z 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. 2 SINGLE FAMILY Temp.Power Pole& Appurtenances ACCT A 4- HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits "30? 63.70 for the following reason (Section 7031.5, Business and Professions Code): ITEll-S rMisc.Conduits& Conductors T! "° 7 I,as owner of the property,will do the work and the structure t 1_I��L _ l d h Fee Schedule) _ is not intended or offered for sale (Section 7044, Business Other (See Complete ® CHECK CiL a7�3 t,• and Professions Code). ,�-�ECK CONSTRUCTION LENDING AGENCY CHANGE .00 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) 4 20 �2 00 - 1) 11 b7Y! $ � 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 above TOTAL FEE information is correct. I agree to comply,with all County ordinances and State laws regulating Electrical wiring, and hereby authorize represent ti/s of this County to enter upon the above-mentioned propert .spec' r ses. SEE REVERSE FOR EXPLANATORY LANGUAGE G w , SigNature of Permittee Date b WORKERS'COMPENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT w' CE-806G (2-80) I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) FOR APPLICANT TO FILL IN JOB Policy No. Company EACH NO. FEE ADDRESS New Residential Bldgs.&Pools Certified copy is hereby.furnished. 1 &2-Family,Sq. Ft. $ $ LOCALITY , Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection❑ CROSS ST Residential Swimming Pools department. O PR OR �Date_ FRMN MEApplicant Outlets: Red,—Light }Sw. `f✓/� MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional • CITY Tel No. } COMPENSATION INSURANCE PLAN CHECK ,APPLICANT (This section need not be completed if the work involved V Lighting Fixtures First 20 io ADDRESS by the permit is for one hundred dollars 0100) or: less.) �, OC Additional O Total No. CITY Tel No. U I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT LV so as to become subject to theWorl'e ' Com ensation Laws. Range_ Heater_D.W APPLICANT CL Oven _�—C1 1� ADDRESS �f�%� 2 Datecant !' ��+ Top _ FAU _W. CITY Tel No. • i. Hood _ Fan _Other_ NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond._ LICENSE OR Exemption, you should become subject to the Workers' - REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE SED BY with comply with, such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR deemed revoked. r Up to 1 Incl. FINAL Over 1 to 10 Inch. I / ) LICENSED CONTRACTORS DECLARATION � Over 10 to 50 Incl. DATE VALIDATION/ U I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL , 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and effect. Services License Number Lie.Class 0.200 Amp. nder 600 V 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 60O.V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances Sign with One Branch CircuitU'.�' .A I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits f` 0 0 0 0 0 License Law for the.following reason (Section 7031.5, Busi- G ness and Professions Code): Misc.Conduits&Conductors 2 ° - 64,75 ❑ I, as owner of the property, will do the-work and the Other (See Complete Fee Schedule)— ° o h�!, l L- h - structure is not intended or offered for sale (Section 7044, Business and Professions Code). 0 1 5_ 3 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE �O -I certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County ordinances an(� State laws regulating Electrical wiring, and hereby aut 4?;pfze representatives o;this County to enter_upon the abovedntioned r e for'inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittbe Date r