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HomeMy Public PortalAbout8704 HERMOSA DR_Electrical__ ORKER'S COMPENSATION DECLARATION 26-6619 DPW 1,2-9„ 6A663 APPLICATION FOR ELECTRICAL PERMIT L1 iha4•I have .'Certificate of consent to self insure, W.a e of Wbrker'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. Company FOR APPLICANT TO FILL IN gpDREGS .►rMO,5�1 ❑ Certified copy is hereby furnished, New Residential Bldgs.8 Pools NO. EACH FEE LOCALITY ❑ 1&2-Family,Sq, Ft. — $ "� Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq. Ft. CROSS ST, Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR Oudeis:Rec. Light Sw. FIRM NAME COMPENSATION INSURANCE - . (. _ (This section need not be compFirst 20 MAIL the work Involved by the permit is for one hundred dollarss($1($100)or less.)' Total No. Additional ADDRESS7C I certify that in the performance of the work for which this permit CIT Tel.No. is issued, 1 shall not employ any person in any manner so as to -, become sub' ct to the Workers'Compensate L Lighting Fixtures First 20 PLAN CHECK � � P 9 9 APPLICANT _ Total No. Additional ADDRESS NODatApp1,after RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE O APPLICANT: If, after making this Certificate of CITY TeI.No. Exemption, you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Cade, you must forthwith comply with such PERMIT — p provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANTJZ U 7- 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 101nc1. (commencing with Section 7000) of Division 3 of the Business and CITY L r T.I.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Ind. LICENSE OR /'� } Over 50 to 100 Ind. FEE NUb1BER t/ Q tl �/J`7 (/1/{�/'J� Class. License Number • • © O LIC.Class_�.a_! Over 100 DISTRICT NO. p PROCESSED BY O // Services,Swbd.,MCC&Panelboards :J ;�JrrlfJ ��;(,t -t_r[%<J � Contracto u �`�" Date / 0-399 Amp.Under 600 V lI (l FINAL 0 DATE I— ❑ am exempt under Sec. 400-1000 Amp,Under 600 V VALIDATION 0 LU Over 1000 Amp.or Over 600 V FL O_ BAP.C.for this reason BRANCH CIRCUIT FEES B' IWU fn Date: 15A,or 20A, 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits i ❑ 41 Or More Branch Circuits p�)_��� t"�;;'g, Exemption for Reg. Maint. Elect. 15A,20A,208V To 2T7V Lighting Br.Circuits I`l(I/ J ? ' SINGLE FAMILY Temp, Power Pole&Appurtenances _ - .-.._... HOME ,- OWNER-BUILDER DECLARATION Sign with One Branch Circuit _ tit.�T.t . I hereby affirm that I am exempt from the Contractor's License Law _ �n for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits - �117 Code): ti ❑ Misc.Conduits&Conductors _ 1 ITEMS I, as owner of the property, will do the work and the structure l is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) - TQTAL J$mcJ-ry and Professions Code). - p1` CONSTRUCTION LENDING AGENCY p_ N`H`�K _ 59p .55 I hereby affirm that there is a construction lending agency for the CHANGE .UO performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) • c • -r Lender's Name PLAN CHECKING FEE .. 0000'0001 1l .Ir'g.i PERMIT ISSUING FEE - •NF4O 1 AYt11:71 . Lender's Address � .. I certify that I have read this application and under pans tyof purjury state TOTAL FEE 4.= 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 his County to enter upon the above-mentioned property for inspec' (p 11�G SEE REVERSE FOR EXPLANATORY LANGUAGE SIGN ATUREOFPERMIITEE PATE WORKER'S thatIhaveCOMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LI 0-001 1 hereby affirm that I have a certificate of consent 10 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. Company FOR APPLICANT TO FILL IN AppRESS 90�/ /"��••r[' ql rhifietl copy is herebyfurnished. NO. EACH FEE New Residential Bldgs.&Pools _ $ $ LOCALITY ❑ Certified co is filed with the count building Inspection 1 &2-Family, Sq.Ft. DY Y 9 P / department. Multi-family Sq. FL NEARESTCROSS ST. O G (y(_ Date Applicant Residential Swimming Pools ASSESSOR ` MAC BOOK �,J�Q PAGE OG PARCEL-(i CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Red._Light Sw, 2wnNn NAOR COMPENSATION INSURANCE Frst 20 MAIL (This section need not be completed if the work involved by the - permit is for one hundred dollars(5700)or less.) Total No. Additional ADDRESS I 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 CK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date I Applicant If,of RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this r ficate of _ CITY T.I.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 Power Apparatus&Large Appliances APPLICANT �^pA-/(,c provisions or this permit shall be deemed revoked, ��(( LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS O L' I Ja I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Ind.(commencing with Section 7000) of Division 3 of the Business and CITY L13S �� I L N0.2G�_ Z3(" Professions Code,and my license is in full force and effect. Over 10 to 50 Ind. LICENSE OR / C' Claee. Over 50 to 100 Ind. REG.NUMBER D a License Number / Li C.Class Over 100 DISTRICT NO. p PRO SSED BY O r^ Services,Swbd., MCC 8 Pa elbooaarrddss�(o ��r7 C 0 Contractor Data !Z ` 0-399 Amp. Urfder 600 V"-' pATEL 0 400-1000 Amp.Under 600 Vy/ ~ ❑ Iam exempt under Sea / J VALIDATION V Over 1000 Amp.or Over 600 V FINAL \ LU B.&P.C.for this reasonBRANCH CIRCUIT FEES BY U) Date: 15A,or 20A. 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Bch Circuits Exemption for Reg.Matnt. Elect. 15A,20A,208V To 27N Lighting Br.ranCircuits .y SINGLE FAMILY Temp.Power Pole&Appurtenances L HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law r' for the following reason (Section 7031.5. Business and Professions Additional Sign Branch Circuits 37 32 -' 19 cc Code): - i 'F HE ❑ 1!Ei I, as owner of the property,will do the work and the structure 1 Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) � TOTAL 5 - 55 and Professions Code). CN59 ;5k .. CONSTRUCTION LENDING AGENCY CHANGE .00I 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 1 I]�! —Ilil r1/25/93 G G1 . Lender's Name PERMIT ISSUING FEE o�� ..'� 77e 96 1 Ail 9;24 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 Count to enter upon the above-mentioned property for spe t n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGMATUREOFPEFI DATE