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HomeMy Public PortalAbout5646 HALLOWELL AVE_Electrical__ DEC TION WORKERS'- Ihave COMPENSATION cafe of corse 76A663 PW 3/87 . A U ��C/r�l�O N FOR ELSECTOU��!/"'UL� pC�63N7 O hereby affirm that I have a certificate of consent to self CEg06G �I (� u insure, ora eertificate'of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS at a certified ycppyy tthereDf (Sec. 3800, Lab.C. Policy No. C t Company FOR APPLICANT TO FILL IN. JOB 'Certified copy`is hereby furnished:. New Residential Bldgs. & Pools EACH NO. 'FEE ADDRESS L v &(_ El❑ Certified copy is filed with the'county buildin inspec- 1 &2-Family, Sq. Ft. LOCALITY_'� — $ - ��.. tion department. Multi-family Sq. Ft. NEAREST �jL�_ Residential Swimming Pools CROSS ST. LOWNEVe Date Applicant FIRM NAME 'CERTIFICATE OF EXEMPTION 1`13@fth-VdBRS' __" _ MAIL , Outlets: Rec Light Sw._ COMPENSATION INSURANCE First 20 i ADDRESS (This section need not be completed if'the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall riot employ any Berson in any manner so as to become subject to the Workers"Compensation Laws: Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date Ppplicant Fixed Appliances Not Over 1 H' PERMIT NOTICE TO APPLICANT: If, after making.this Certificate of , Exemption, you should become subject.to the Workers' Range— Heater—D.W. APPLICATION —- 6,10Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 6A Lin E� with comply,with such provisions or this permit shall be Top FAU —W.H. !— deemed revoked. Hood — Fan —Other— CITY. Tel. No.O o I LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus.& Large Appliances f DISTRICT NO. P O ESSED BY >_ and Professions Code,and my license is in full force and effect. p a p' p Size & Type HP, KW, KVA, or KVAR O .�L 0 License Number (93 7S 3 'Lic. Class Up to 1 Incl' FINAL r 0 Over 1 to 10 Incl. DATE Z_ 61 _L{ 3 �. VALIDATION Contractor t 9� '�V'W Date A e" i-- Over 10 to 50 Incl. TIN0 J_ ❑ I am exempt,under Sec. Over 50 to 100 Inc. BY AL U LLl Over 100 B.$P.C. for thi � - d DZ Services, Swbd., MCC & Panelboards z ate: 0-200 Amp. Under 600 V — ignature 201 - 1000 Amp: Under 600 V - Over 1000.Amp. or Over 600 V Exemption for.Reg. Maint. Elect.. SINGLE FAMILY HOME OWNER-BUILDER DECLARATIONTemp. Power Pole &Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit `l ` Law forthe following reason (Section 7031.5, Business and Additional Sign Branch Circuits -Conduits& Conductors - Prefeions Code):- .. .... 3 s owner-,of the property, will 'do the work and the Misc. structure is not Other Complete intended or offered for sale(Section 7044, ( P Fee Schedule)— Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for f' M'RI'-• the performance of the work for which this..permit is issued PERMIT FEE ` (Sub-Total) (Sec. 3097, 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 TOTAL FEE rOf3 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 ©s Signciture 46f Permittee Date WORKERS'COMPENSATION DECLARATION 76A663 DPW 3/87 I hereby'affirm that.l have a certificate of consent to self cE 806G insure, or certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS er a certified.s''oQQpy thereof (Sec. 3800, Lab..C.) Policy No.�l�� Company S7 T•CJarO FOR APPLICANT TO FILL IN JOB �erlified copy'is hereby furnished: New Residential Bldgs. & Pools EACH NO. FEE ADDRESS66�64 49VL Certified copy is filed with the y build' g inspec- l & 2-Family, Sq. Ft. $ — $ LOCALITY TV tion de ortment. — NEAREST p Multi-family Sq. Ft. Residential SwimmingPools CROSS ST. Date ¢ �- Applicant - OWNER OR ,may `6 A FIRM NAME [ /T�(J V CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets: Rec Light Sw._ COMPENSATION INSURANCE r- ADDRESS (This section need not be completed if the work involved b First CITY Y Total No. Additional 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 Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT .�-- NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION ( w/1 Wag w 0 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. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P O SED BY >_ and Professions Code,and my license is in full force and effect. , CL O Size &Type HP, KW, KVA, or KVAR License Number Y.F5 7111 Lic. Class Up to 1 Incl. FINAL U Contractor ��- '/� Date ��7� L_-- Over 1 to 10 Incl. DATE 2_(4_.q+ 3 VALIDATION � Over 10 to 50 Incl. FINAL H j I am exempt under Sec. Over 50 to 100 Inc. BY Q B.&P.C. for this reason Over 100 Dat Services, Swbd., MCC& Panelboards D Z 0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V ZI-Exemption for Reg. Maint. Elect., , SINGLE FAMILY TempPower Pole &Appurtenances X. . HOME OWNER-BUILDER DECLARATION 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 �:;-•.:—;- Professions Code): " � Misc. Conduits&Conductors # ) (z_ 16� 1, 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)_ l Business and Professions Code). CONSTRUCTION LENDING AGENCY - II I hereby affirm that there is a construction lending agency for W the performance of the work for which,this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE oZ� Lender's Address - 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 56 11 ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for in purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE. �, ; Sign tur of Permittee Date ©s