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Home My Public Portal About4843 HALLOWELL AVE_Electrical__ ► WURKSTR'S COMPENSATION DECLARATION 20-0019PPVJ(12=31) 76A663 APPLICATION FOR ELECTRICAL PERMIT --i I hereby affirm that. rilaave a certificate of consent to self insure, or a certificatrrof 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.) FOR APPLICANT TO FILL IN JOB Policy No. Company ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY ❑ _ $ $ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR pp MAP BOOK g PAGE OIrJ PARCEL D� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNNAME y , + COMPENSATION INSURANCE IS V First 20 FIRM 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 �f Tel.No g-& is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Com ensatior' Laws. Lighting Fixtures First 20 APPLICANT 4 c Total No. Additional ADDRESS ` Date r� Applicant S �" ' RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making thi Certificate of CITY Tel.No. Exemption,you should become subject to the Work s' 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 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. LICENSOR E Over 50 t0 100 Incl. REG.NUMBER CL Over 100 DISTRICT NO. TPhD4�� License Number Lic.Class �" /� V Services,Swbd.,MCC&Panelboards `J " �./ � 11: Contractor Date 0-399 Amp.Under 600 V DATE ) 0 400-1000 Amp, Under 600 V I-_❑ 1 am exempt under Sec. 17,A61It VALIDATION V Over 1000 Amp.or Over 600 V FINAL W B.&P.C.for this reason BRANCH CIRCUIT FEES BY I/ � Date: 15A,or 20A, 120V,Lighting or Recept. ;1 Z_ 1-To 10 Branch Circuits n� 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 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits3�,5 Code): U ❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ✓��j� and Professions Code). oil. 1 CONSTRUCTION LENDING AGENCY 1 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 2_� PERMIT ISSUING FEF_ 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 i coon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE Of-PERMIT E DATE WORKERS'COMPENSATION DECLARATION -663 10/81 CE-806G APPLICATION FOR ELECTRICAL PERMIT %I'hereby.affirm that I have a certificate of consent to sel,insure, CE or'aycertificate'of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY %opy theredf(Sec.3800,Lab. C.) ' "Policy No. Company FOR APPLICANT TO FILL IN JOB /'� .,• �/ AVC—,,) f� ❑ Certified copy is hereby furnished. New Residential Bldgs. EACH NO. FEE ADDRESS L�& Pools ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY L G CA Certified copy is filed with the county building inspection �e t'� TY department. Multi-family Sq.Ft. NEAREST CROSS ST. 'ZLA APAD Date Applicant Residential Swimming Pools OWNER OR FIRCERTIFICATE OF EXEMPTION FROM WORKERS' MAIM NAME Outlets:Rec Light Sw. hVI' COMPENSATION INSURANCE I� ADDRESS VV First 20 (This section need not be completed if the work involved by the CITY Tel.No., J• permit is for one hundred dollars ($100) or less.) Total No. Additional ,� �n I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person in any manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If; after making this Certificate of 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. LICENSED CONTRACTORS DECLARATION CITY Tel.No. Hood � Fan � Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Dis LICENSE OR (commencing with Section 7000) of Division 3 of the Business and p Room Air Cond. REG.NUMBER Class. Professions Code,and my license is in full force and effect. .DISTRICT NOPR SSED BY Power Apparatus& Large Appliances Size & Type HP,KW,KVA, or KVAR QC7 . 50U License Number Lic. Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE . ,• VALIDATION O Contractor Date Over 10 to 50 Inc]. FINAL 9 6 U ❑ I am exempt under Sec. Over 50 to 100 Inc. BY �J`ei0. B.&P.C. for this reason Over 100 fn Date: Services,Swbd.,MCC& Panelboards ® Z 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. SINGLE FAMILY Temp. Power Pole& Appurtenances i HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit A41;Tn4 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ACCT. Code): c ❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 ITEMS Gt tJ is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ , TOTAL 93.25 and Professions Code). CHECK 93.25 CONSTRUCTION LENDING AGENCY I 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) Civ. C.). Lender's Name PLAN CHECKING FEE 0000-0001 10/11/89 to PERMIT ISSUING FEE 1 iv'y 1 AIIit1e � Lender's Address � o d 1V 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 representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Date