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Home My Public Portal About9010 HERMOSA DR_Electrical__ WORKER'S COMPENSATION DECLARATION 720-0019 6A663 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT I hereby a:firm that I 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.) �� /fi PaliCy N(9/.�C��/3 Company.49:4� ��2y�'� FOR APPLICANT TO FILL IN U06 94/0 J /�+�Al a p� sL ❑ /�/ / ADDRESS �-/UT V ✓G Certified copy is hereby furnished. % New Residential Bldgs.&Pools NO. EACH FEE ❑ $ $ LOCALITY Certified copy is filed with the county building inspection 1 &i--Family,Sq. Ft. depg[,tn entp._ ` Multi-family Sq.Ft. Coos sr. �te G �o Applicant ✓ Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw._ OIW ER OR COMPENSATION INSURANCE FIRM NAME FIB(20 MAIL (This section need not be completed It the work involved by the Total No. Additional ADDRESS permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit CITY � TeI.No. Is issued, I shall not employ any person in any manner so as to PLAN CHECK WL� become subject to the Workers'Compensation Laws, Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Dale Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO 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 Code, you must forthwith comply with such Power Apparatus&Large Appliances APPLIPERMITCA &yp J,Q provisions or this permit shall be deemed revoked. ' / LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,ki or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 - CY (commencing with Section-7000) of Division 3 of the Business and Over 3 to 10 incl. CITY! Professions Code,and my license is in full force and effect. Over 10 to 50 mc1. } LICENSE OR ./ - / Glass.�!� d 9ryr Over 50 to 100 Incl. REG,NUMBER License Number //� �/ Lic.Claes /o Over 100 DISTRICT NO. ` PR C SED BY O /,�/!�(/�/per. Se Sw/yi..MCC, QgNP"Ib ds �� r1 , LC Gontrac"toF n Date 0"-3919�fAJmP. nll FINAL ❑ I am exempt under Sec. 400-1000 Amp. Under 600 V W Over 1000 Amp.or Over 600 V FINAL �i VALIDATION a B.&P.C.for this reasonBRANCH CIRCUIT FEES BY (DO Z Date: 15A,or 20A, 120V,Lighting or Recept 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 HOMEOWNER-BUILDER DECLARATION .r.�.� ith Cir Sign with One Branch cu I hereby affirm that I am exempt from the Contractor's License Law Sig _ for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits `._11,1 63.45 Code): F-1 1, Conduits&Conductors 1 IT r13 I,as owner of the property,will do the work and the structure is not intended or offered for sale Section 7044, Business Other See Complete Fee Schedule TOT^ 45 and Professions Coda). Pool t-Hr4,` jjv -` CONSTRUCTION LENDING AGENCY L _ I hereby affirm that there is a construction lending agency for the. CHANGE .Ulf performance of the work for which this permit is issued(Sec. 3D97, PERMIT FEE (Sub-Total) Civ. C.) PLAN CHECKING FEEj1 iI II _I C`I;( q/ OTC' . Lender's Name h / PERMIT ISSUING FEE 010; Lender's Address �� /✓ I certify that I have read this application and under penalty of perjury state TOTAL FEE 'SAS 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATUR FPERMIIT 1 DATE 'WORKERS'COMPENSATION DECLARATION zo.wts ovw 3ie7 APPLICATION! FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self .CE.CE_8D6 � insure, or a certificate of Workers' Com ensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certifi d7f co y thereof ('�S/e-. 38 Lb/�.,Cl)�/l`L'�IJn'.�t-/o Policy No '" 9��'SCbmpan ,nr FOR APPLICANT TO FILL IN JOB F-1 Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS C/ (}U,'Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. $ — $ LOCALITY L[[��tt tion depo�Jrt,m((en�t. Multi-family Sq. Ft. — NEAREST CROSS-�X`f'-/� / C Iht/` RORS T. Date gpplicant /- Residential Swimming PoolOWNER FIRM NAME CERTIFICATE OF EXEMPT FROM WOR S' Outlets: RecZLight�5w. MAIL p, COMPENSATION INSURANCE r 416 ADDRESS (This section need not be completed if the work involved by CITY Tel. No 8'7 the permit is for one hundred dollars ($100)or less.) Total No. Additional First 20 J certify that in the performance of the work for 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 Date Applicant Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over I HP PERMIT APPLICATIO i .( Exemption, you should become subject Io the Workers' Range— Heater—D.W. Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M._ ADDRESS ,G with comply with such provisions or this permit shall beZP_ deemed revoked. Hood — Fan —Other— CITY LICENSED CONTRACTORS DECLARATION Disp. _ Room Air Cond. — LICENSE OR �� ClassCl Z I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PRO §SSED BY Y and Professions Code,and my license is in full force and effect. p C% Cd /7S/ k Size 8 Type HP, KW, KVA, or KVAR .QO Q License Nu er Lic. Class �� Up to 1 Incl. FINAL CJ i �� Over 1 to 10 Ind. DATE _ Qi,9? VALIDATION Contracto Date Over 10 to 50 Incl FINAL J F_ ❑ 1 m exempt a f r Sec. Over 50 to 100 Inc. BY C) Over 100 111 B.BP.C. for this reason d Date: Services, Swbd., MCC 8 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. Mainz. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit F'41_(.T.t Law for the following reason (Section 7031.5, Business and Additional Sign Branch,Circuits Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors IT`Y structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ -jiijHL 50 a5 5 Business and Professions Code). s. s c- cc CONSTRUCTION LENDING AGENCY CH Ef_fil{3.:r:� I hereby affirm that there is a construction lending agency for CHANGE I( the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) �� 4/_0 - - (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Nome � PERMIT ISSUING FEE Lender's Address thatI0 I certify that have read this application and state that the TOTAL FEE J/ 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 t ov e u ned propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /bildridt.re of PP tee Date