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Home My Public Portal About9026 HERMOSA DR_Electrical__ WOR.at I have a certificate DECLARATION 76A669DPW(,2-9„ APPLICATION FOR ELECTRICAL PERMIT IJ 0-001 I hereby,affirm Igat I have a certificate of consent to self insure, or a certificates of Worker's.Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy lhereoflI Lab. C.) Policy NO. � ''°'� Company F1'r�M✓ � FOR APPLICANT TO FILL IN gppRE53 ® �(J YJ Certified copy is hereby furnished. New Residential Bldgs.&POOIa NO. EACH FEE /'e O $ $ U LOCALITY ❑ Certified co is filed with the count building inspection 1 &2-Family,Sq,FL G T PY Y 9� P NEAREST depart ent. Multi-family Sq. Ft. CROSS ST. _ Date � /� �Applicant y til. Residential Swimming Pools ASSESSOR ,i Tom— �--• MAP BOOK �/D 7 pgGE 1:59,P7 PARCEL e10 CERTIFICATE OF EXEMPTION FROM,WORKERS' OWNEROR `( L - Outlets:Ren.—Light Sw. FIRM NAME COMPENSATION INSURANCE I, First 20 MAILl�, (This section need not be completed If the work involved by the Total No. Additional ADDRESS 10' ZIZ bK permit is for one hundred dollars(5100)or less.) _. certify that in the performance of the work for which this permit CITY A Tel.NoIt- 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 No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.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 / d provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT ' T `/ i7 C LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS �. w hereby affirm that am licensed_under_provisions of_Chapter_9 - - =Over.3 to.10:IncL--- (commencing - - - ) _ _ _ --- — _ - 'CITY= �� —_�'GP'•(.� —:TeI.Na.- `-5�.� 3 chereby ff with Section icer of Division 3 of the Business and 4= Professions Code,and my license is in full force and effect. Over 10 Yo 50 InCIL LICENSE OR 1--'•n� �^ Over 50 to 100 Incl. REG.NUMBER Class. d License Number e �' ( Lic.Class [ (G, Over 100 DISTRICT NO. p SSED ev C) Services,Swbd.,MCC&Panelboards' Contract6F `--`' -� ate �`'- T 0-399 Amp.Under 600 V Foie '7 O ❑ 400-1000 Amp.Under 600 V VALIDATION I am exempt under c. W Over 1000 Amp.Of Over 600 V FINAL - d B.&P.C.for this reasonBY U) BRANCH CIRCUIT FEES Date: IRA,or 20A, 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 4D Branch Circuits F-141 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V TO 277V 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 Code): ❑ 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 I hereby affirm that there is a construction lending agency for the p performance of the work for which this permit is issued (Sec. 3097, PETMgO FEE n (Sl-diNfotal) O G Civ. C.) F-f_j 2 r. 4�yW9J PLA +HECKING E m 7D"4 Lender's Name 1 - F r t•' nn PER4 ISSUING? E 4i• OA Q F-a Lender's Address ,y I certify that I have read this application and under penalty of.purjury state TOWFEE / that the above information is correct. f 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 REVERSER EYPLANATORrNANGUAGE �_, .�. P/� o !-J d SIGNATURE F P,,, EE DATE �� O DEC WORKERS' Ihave COMPENSATION cafe of corse 76AW DPW 3/8I APPLICATION FOR ELECTRICAL PERMIT O 20A= I hereby affirm that I have a certificate of consent to self .cE,eosc insure, .or,.o certificpte of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lob. C.) - Policy.No. Company FOR APPLICANT TO FILL IN SOB /,•O� / ❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS ❑Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft.o�?aa 3 LOCALITY lion department. Multi-family Sq. Ft. — NEAREST CROSS Date Applicant Residential Swimming Pools OWNERSOR_ Cm T. FIRM NAME / CL"L� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight_Sw._ MAIL COMPENSATION INSURANCE First 20 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 ork for hich this APPLICANT permit is issued, shall not employ any p rson in a manner so as to become subject to the Workers' so ion Laws. Lighting Fixtures First 20 ADDRESS Additional Dote ___- -~ _Applica t Total No. CITY Tel. No. NOTICE TO APPLICANT: If, aft .king this Certificate of Fixed Appliances Not Over I 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 _ deemed revoked. od — Fan — CIT Tel. N v( LICENSED CONTRACTORS HoOther_ _RS DECLARATION Ho _ Room Air Other— LICENSE OR I hereby affirm that am licensed under provisions of Chapter 9 Disp' - - - - -- - - -- REG..NUMBER ordClass. (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PR CSSED BY Y and Professions Code,and my license is in full force and effect, y a- rc? Size 8 Type HP, KW, KVA, or KVAR Q 0 Q License Number Lic. Class Up to I Incl. FINAL U �J�' ��,( 1'1=^�-� Over 1 to 10 Incl. DATE S VALIDATION Q ContractorERI F Dote)—LQ _ Over 10 to 50 Incl. FINAL H- ❑ I am exempt under Sec. Over 50 to 100 Inc. BYW B.BP.C. for this reaso Over 100 0- Da e: 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(29. Maint. Elect. Sr-.-r SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOMEOWNER-BUILDER DECLARATION - '':') 7 '�rz -?"'• Ihereby 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 j T 1_rl_; 'Professions Code): IiIZ WCWKER'S COMPENSATION DECLARATION 76ASS3 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT 6A663 I hereby affirm'that I'have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, of 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 Certified copy is hereby furnished. New Residential Bldg$.&Pools EACH NO. FEE LOCALITY ❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.FL $ — $ ST `` • ^ , A r\ department. Multi-family Sq.Ft. NEANEARERS ST. IJ LLJ I./ Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK I PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' , Outlets:Rec. Light Sw. OWNER OR FIRMNA COMPENSATION INSURANCE First ME (This section need not be completed If the work involved by the ADDRESS permit is for one hundred dollars($100)or less.) Total No. Additional MAIL ional I certify that in the performance of the work for which this permit - CITY - Tel.No, is issued, I shall not employany person n any me net so as to become subject to the Workers'Com p s Lighting Fixtures First 20 AILA ANTK Total No Additional ADDRESS Date"_ :5z APPlica 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, to aking this Certificate of CITY O TeL No. Exemption,.you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH `3 178 0 provisions of the Labor Code, you must forthwith comply with such -11 TO 40 INCLUSIVE EACH PERMIT P Y PY - APPLICANT ' provisions or this permit shall be deemed revoked. dt OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS EL I hereby affirm that I am licensed under provisions of Chapter 9 150E 20A,208V TO 27N LIGHTING EACH G.. (commencing with Section 7000) of Division 3 of the Business and . . CITY Tel.No. 0 Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR Q _ Power Apparatus&Large Appliances REG.NUMBER Class. License Number, Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY O - Up to 31nc1. U�:D� ��y.=Ac--c/r+ W Over 3 to 10 Incl. FINAL Q. Contractor Over 10 to 50 Incl DATE C0 ❑ — VALIDATION I am exempt under Sec. Over 50 to 10_0 Incl. _ FINAL BAP.C,for this reason Over 100 BY Services,Swbd.,MCC.&Panelboerds Date: 0-200 Amp.Under 600 V Signature 201-1000 Amp.Under 600V ❑ Over 1000 Amp.or Over 600 V _ Exemption for Reg.Mainz.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances f_4.T, a HOME OWNER-BUILDER DECLARATION - A it Sign with One Branch Circuit [ I hereby affirm that I am exempt from the Contractor's License Law Sig '-�17 IS",.�l) for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits. -�'d` Code): I i C.I Iv ❑ Misc.Conduits'&Conductors T_ITyL m I,as owner of the property,will do the work and the structure TC UAL not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 60 and Professions Cade). - — , - - CASH 61•,6.13 CONSTRUCTION LENDING AGENCY �;firhv(3E .!Ili I 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.) I1'i 1 f gln'7 PLAN CHECKING FEE 0 V41:f_ C,1 16 Lender's Name .� ccc: 1AM PERMIT ISSUING FEE � ✓:.f Lender's Address I certify that 1 have read this application and state that the above TOTAL FEE 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 SIGNATURE OF APPLICANT OR AGENT DATE