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Home My Public Portal About5569 HALLOWELL AVE_Electrical__ ?NORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT I Feaeby affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB _ I FICertified copy is hereby furnished. New Residential Bldgs. & Pools. EACH NO. FEE ADDRESS 7377 t��Wex Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $,496 — $ LOCALITY G tion department. Multi-family Sq. Ft. NEAREST , Date Applicarit Residential Swimming Pools CROSSOWNEST. r%rr—,o ' FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ 4 MAIL c ll COMPENSATION INSURANCE First 20 ADDRESS Q O J GL ' (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Date Applicant � Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No, LICENSED CONTRACTORS DECLARATION LICENSE OR REG. NUMBER I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PRO SSED BY >_ and Professions Code, and my license is in full force and effect. 0- Size Size &Type HP, KW, KVA, or KVAR �> 0 License Number Lic. Class Up to 1 Incl: FINAL U Over 1 to 10 Incl. DATE 4 VALIDATION Contractor Date 0 r_1 Over 10 to 50 Incl. i FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 t1 Services, Swbd., MCC& Panelboards Z Date: 0- 200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V El Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits `^'=s Pro essions Code): y I f' >�4°11 E Conduits&Conductors I, as owner of the property, will do the work and the Misc. i �')•' IL-, structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). CONSTRUCTION LENDING AGENCY _:l l•L'"{_:); :r; I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) U ':S€Hl1F,71=. ,C4 (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name /� r_) .1y1 —_till PERMIT ISSUING FEE - Lender's Address t� 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 and State laws regulating Electrical wiring, and teb y authorize representatives of this County to enterbove entioned property for inspection puSEE REVERSE FOR EXPLANATORY LANGUAGE ture of Per ttee ate Os l WORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O .14 m l he�eby affirthat have a certificate of consent to self CE-BO6G isute, or a certificate of �I;orkers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or"V-certified copy thereof (Sec. 3800, Lab. C.) 'Policy No. ADDRESS Company FOR APPLICANT TO FILL IN JOB / ` C U!"-�.&C, Certified copy is hereby furnished. New Residential Bldgs, & Pools EACH NO. FEE 7 _ LOCALITY Certified copy is filed,-with the county building inspec- 1 & 2-Family, Sq. Ft. $ $_ �Y tion department. Multi-family Sq. Ff. CROSS ST. ��; 0 Date Applicant Residential Swimming Pools OWNER OR yt FIRM NAME 1 3,F� l✓� 1 oz� Z CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS (This section need not be.completFirst 20 -ed if the work involved by Total No. CITY- Tel. No. ��5 the permit is for one hundred dollars ($100)or less.) Additional .. �� r I certify That in the performance of the workfor which this PLAN CHECKAPPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven ^ Dryer ,W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. -CITY Tel. No. LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— Dis Room Air Cond. LICENSE OR I I hereby affirm that I am licensed under provisions of Chapter 9 p REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROBY >_ and Professions Code,and my license is in full force and effect. d Size &Type HP, KW, KVA, or KVAR7 Q License Number - lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATE jaw ) _Q�� VALIDATION 0 OOver 10 to 50 Incl. FINAL j` (( // am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 Services, Swbd., MCC & Panelboards , Date: 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V DOver 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances - HOME OWNER-BUILDER DECLARATION Sign-with One Branch Circuit ",5: o • I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): Misc. Conduits&Conductors ❑ I, as owner of the property, will do the work and the structure is not intended or offered for.sale(Section 7044, Other (See Complete Fee Schedule)— - i1 iH_ Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for f:r' the performance of the work for which this permit is issued PERMIT FEE °`H x`'t" p p (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name '_I'_'Is F; (•-€ PERMIT ISSUING FEE 00 _ •:•t<t s Lender's Address I certify that I have read this application and state that the TOTAL FEE DYJ above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby aut orize representatives of this County to enter upon the ab ov mentioned property,for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r Signa re of Permittee Date Os