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Home My Public Portal About8807 HERMOSA DR_Electrical__ WORKER'S COMPENSATION DECLARATION 76A663 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT �J I hereby affirm that 1 have a certificate of consent to 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 N0. Company FOR APPLICANT TO FILL IN JOB ti ❑ ADDRESS L) VS'� Certified copy is hereby furnished. New Residential Bldgs.8 Pools NO. EACH FEE LOCALITY `—+ ElCertifiedcopy is filed with the county building inspection 1 &2-Family,Sq.Ft. — $ $ department. Multi-family Sq.Ft. oao9355T. Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM NAME PA 0 (This section need not be completed First 20 MAIL the work involved by the Total No. Additional ADDRESS �) 7 permit is for one hundred dollars(5100) or less.) I certify that in the performance of the work for which this permit CITY Tel. 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 PLAN CHECK 9 9 APPLICANT q Total No Addi@onai ADDRESS Date 1J °" Applicant r l`r RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE O A PLICANT: If, after ma;Ing'this Certificate of CITY Tel.No. Exemption, you should became subject to the Workers' 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 1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 101nc1. n x (commencing with Section 7000) of Division 3 of the Business and CITU Professions Code, and my license is in full force and effect Over IO to 50 Inc? LICENSE OR _ Class. r-� Over 50 t0 100 OC. REG.NUMBER ��' [� ('�/ Over 100 DISTRICT NO. PROCESS V Q License Number � I / Lic.Class �I 0 /r r ,n 'y�'/I 1. (, Services,Swbd.,MCC&Panelboardscc Contractor ( N�}i(/tS ,��/`'—L` p l�`�� iJ ry FINA 0 0-399 Amp.Under 600 V ❑ a 400-1000 Amp.Under 600 V DATq Q{{ am exempt under Sec. .5 —22, /n VALIDATION LU Over 1000 Amp.or Over 600 V FINAL W B.&P.C.for this reason BRANCH CIRCUIT FEES er �/ � Date: 15A,or 20A, 120V,Lighting or Recent. 41�Q L Z 1 To 10 Branch Circuits V 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 i for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): A�CCT.i 61.40❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors OI 01.ft� is not intended or offered for sale (Section 7044JJ , Business Other(See Complete Fee Schedule) , JJ i ITEMS and Professions Code). 1 1 CONSTRUCTION LENDING AGENCY TOTAL 61 - 40 I hereby affirm that there is a construction lending agency for the CASH t.r OLet(� performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Y Civ. C.) .00 PLAN CHECKING FEE {:RANGE Lender's Name y PERMIT ISSUING FEE Z! 0000-0001 5/20/96 Lender's Address //�1 1 certify that I have read this application and under penalty of purlury state TOTAL FEE /' O 6532 1 PM 5.36 that the above information is correct. I agree to comply with all County f 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 SIGNATUCPEFMITiEE TE • WORKER'S COMPENSATION DECLARATION 9DPW„2-91) 76AR63 APPLICATION FOR ELECTRICAL PERMIT J BA66 - I hereb}affirm tllaY I have a certificate of consent to self insure, or a cArtificato 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 JOB tl/20' �r .�j_q-Y ,SLA r�xyp ADDRESS (/Z7 E rz /rd Y K Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY ❑ FL Sq. — $ $ Certified copy is Filed with the county building inspection i&2-Family. NEAREST {�v department. Multi-family Sq. Ft. CROSS ST Date Applicant Residential Swimming Pools ASSESSOR / MAP BOOK ) PAGE `� PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. b Ram Nn ME t1Jy G,ealO COMPENSATION INSURANCE First 20 (Tbis section need not be completed if the work involved by the '1_0v MAIL ryAM AppRESG permit is for one hundred dollars(5100)or less.) Total No. Additional I certify that in the performance of the work for which this permit CITY Tel.No.76 .is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting.Fixtures / First 20 APPLICANT Total. Additional ADDRESS Dale Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY T.I.No. Exemption,you should became subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP. d � provisions of the Labor Code, you must forthwith comply with such PERMIT ra-^GCY provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HE,KW,KVA;or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over3to 10 Ind.(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 Inc. LICENSE OR Y Class. Over 50 t0 100 InREG.NUMBER cl. CL Over 100 DISTRICT NO. P SSED By C..) O License Number i Class Services,Swbd.,MCC&Panelboards Ir Contractor Date 0-399 Amp.Under 600 V DATE O ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V /. W Over 1000 Amp.or Over 600 V FINAL VALIDATION IL B.&P.C.for this reason BRANCH CIRCUIT FEES BV 00 Date: 15A,or 20A, 120V,Lighting or Recept. &CVZ 1 To 10 Branch Circuits 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 fallowing reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits — — —7 yj 1 €Code): .666-6 L� L as owner of the property, will do the work and the structure Misc.Conduits&Conductors _ 7 ,+i I C.4- Is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , •€T ';6 ( and Professions Code). Ir^ 'rAL CONSTRUCTION LENDING AGENCY t_UiLi'+ zlU I hereby affirm that there is a construction lending agency for the -- — CHANGE - - ,0(11 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) ,;� Civ.C.) PLAN CHECKING FEE _ �.t Lender's Name // PERMIT ISSUING FEE �(O tiM[€_I, 1'}y1•j ¢€I i} Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE 3i that the above information is correct. I agree to comply with all County .. ordinances and State laws regulating Electrical wiring,and herebyauthorize representatives of this County to enter upon the above-mentioned property for inspection pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE SISI NATI IFF I n TE WORKER'have a ENSATIO"I DECLARATION 20 0019 (12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby.affirm that Ihave a cern/iL�e of consent to 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.3.800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Slogs.&Pools NO, EACH FEE ❑ $ $ LOCALITY Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. j Aid department. Multi-family Sq.Ft. CROSSSST, Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec. Light1_4 Suv. , ORM NAM COMPENSATION INSURANCE E YiA/0 F70 Additional 20 MAIL �}gv y- Ff&P t��( 11 y?R (This section need not be completed If the work Involved by the Total No. First 0 ADDRESS Q O r/ O a I_( J`v Yv permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit I CITY r - ( L� G�t' Tal.No. Is issued, I shall not employ any person In any manner so as to PLAIN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures 2 First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 i1p. NOTICE TO APPLICANT: If, atter making this Certificata—,t CITY Tal.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 Op�� 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 Ovar3lo 101nc�. (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 Ind. } Over 50 to 100 Incl. FEGNNUM ER SE OF Class. d License Number Lic.Class Over 100 DISTRICT NO. PROCESSED BY O Services.Swbd..MCC&Panelboards Contractor Date 0-399 Amp. Under 600 V FINAL DATE ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V _ _ VALIDATION W Over 1000 Amp.or Over 600 V FINAL d B.&P.C.for this reason BRANCH CIRCUIT FEES BY lJ) Date: 15A,or 20A, 120V,Lighting or Recept. QZ 1 To 10 Branch Circuits rS Signature 50 11 To 40 Branch Circuits r_1 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 27TV Lighting Sr.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 Circuits (((Cootl((de): I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors / is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ' and Professions Code). ' CONSTRUCTION LENDING AGENCY t' ` I herebyaffirm that there is a construction lending agency for the S 9 9 Y performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total ''ii [ 7n 4 Civ. C.) ) V %„�Ll,j 7 II PLAN CHECKING FEE I ITFNS Lender's Name PERMIT ISSUING FEE TOTAL 1 :19 = 40 Lender's Address I r I certify that I have read this application and under penalty of purjury state TOTAL FEE ' \ 1 0 CEO' 11-9.411 that the above information is correct. I agree to comply with all County "�� .r- `�A ordinancesandStatelawsregulatingElectricalwiring,and herebyauthorize _ N1 representatives of this County to enter upon the above mentioned property for inspection purposes. ^ � 7- CIL REVERSE FOR EXPLANATORY LANGUAGE 11111—A Q/23/94 ry0 .y BIGTURE OF PER EE ATE �GO i Ih .vel).