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Home My Public Portal About5519 HILTON AVE_Electrical__ WORKERS'COMPENSATION DECLARATION -663 10r61 CE-ap6G APPLICATION FOR ELECTRICAL PERMIT �1 v CELJ I,hereby affirm that I have a certificate of consent to self insure, or a certiftate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES*/9 3 Q BUILDING AND SAFETY copy thereof(Sec. 3600,L2b. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB r ❑ ADDRESS Certified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ❑ — Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ $ LOCALITY. department. Multi-family Sq.Ft. — NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME Outlets:Rec�� CERTIFICATE OF EXEMPTION FROM WORKERS' Light — t 2 Z MAIL COMPENSATION INSURANCE �Z ADDRESS ' ' This section need not be completed if the work involved ti the / q First 20 ( p y Total No._� Adtlitional CITY j TeL No. permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person in any manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Date �� Applicant Total No. CITY Tel.No. NOTICE T APPLICANT: If, after ma g thi Certificate of Fixed Appliances Not Over 1 HP PERMIT /J_ Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT L-O provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer_ W.M. _ ADDRESS 5 8 provisions or this permit shall be deemed revoked. Top FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood 1�1 Fan _ Other_ CITY. I hereby affirm that I am licensed under provisions of Chapter 9 Disp. + Room Air CorxL 0 LICENSE OR �� / 3 Class.C d (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER fO Professions Code,and my license is in lull force and effect. DISTRICT NO . PROCESSE BY Power Apparatus& Large Appliances Or _ '/ Size& Type HP,KW,KVA,or KVAR J 9 Q License Number� 6 1 3 Lie.Class e" d Up to 1 Incl. FINALId V q Over 1 to 10 Incl. DAT (_l VALIDATION Q Contractor Date l�/ Over 10 to 50 Incl. FIN F- E] I am ex not un, r Sec. Over 50 to 100 Inc. BY W B.&P.C,for this reason Over 100 N Services,Swbtl.,MCC& Panelboards / , Z Date: 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint. Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole & Appurtenances 2 _ HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit y I hereby affirm that I am exempt from the Contractor'sLicense Law Additional Sign Branch Circuits ACCT'4 for the following reason(Section 7031.5, Business and Professions 9 Code): 33307 45•00 ❑ Misc.Conduits& Conductors 1 ITEMS I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) is not intended offered for sale (Section 7044, Business and Professions Cs otle). ► ��T.�d�,��T..U1A�L �t� a Or�rd� CONSTRUCTION LENDING AGENCY - CA�M, 45.00 I hereby affirm that there is a construction lending agency for the Cpw�uG .00 performance of the work for which this permit is issued(Sec.3097, PERMIT FEE - (Sub-Total) Q Civ.C.). Lender's Name PLAN CHECKING FEE i OODD—DUDi 5�12/�9 . .PERMIT ISSUING FEE Q 4 Lender's Address ,1 x256 1 AM 4:45 I certify that I have read this application and state that the above TOTAL FEE r OV 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 tig t re of P ittee Datt WORKER'S COMPENSATION of consent DN 76A669 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 0-001 I hereby affirm that I have d•.erf ificate 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 No. Company FOR APPLICANT TO FILL IN JOB - p ❑ ADDRESS l CertiSietl copy Is hereby furnished. NO New Residential Bides.&Pools . EACH FEE LOCALITY ❑ 1&2-Family,Sq. Ft.-- SL��_ $ $ Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. CROSS ST. A Date vA fpplicant Residential Swimming Pools ASSESSOR '')) MAP BOON PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rea 3J_Light—Sw. OWNER OR COMPENSATION INSURANCE First 20 �I�p% MAIIRM NAME UIII (This section need not be completed the work involved by the Total No. Additional ADDRLESS permit Is for one hundred dollars($1000)or less.) SSW Rilrilit-4 I certify that in the performance of the work for which this permit CITY T Tel.No. is issued, I shall not employ any person in any Tel so as toit CL �J/ PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT 61� Total No. G Additional �L .L ADDRESS Y - .� E Date Applicant ESID N 1 PP IANC S N T V P. ✓V v� ` y NOTICE APPLICANT: after making this Certificate of CITU L x` tel.No. Exemption,,you should becomea subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply withsuch PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT y LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR -ADDRESS a. /h/t if6t, Ave I hereby affirm that I am licensed under provisions of Chapter 9 ,\ ""f (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Ind. / CITY C ?A Tel.No. 0e Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR } Over 50 to 100 Ind. REG.NUMBER Class. 4. Over 100 DISTRICT NO. CESSED BY Q License Number Lic.Class r Q Services,Swb CC.�&/,Pla-�neell o u:15 �• �� La—Gnt✓ CC Contractor Date 0- p.Untler 600 V FINAL / ❑ DATE F' am exempt under Sec. 400-1000 Amp,Under 600 V -�'•� VALIDATION W Over 1000 Amp.Or Over 600 V FINAL fl B.&P.C.for this reason BRANCH CIRCUIT FEES By U) Date: 15A,or 20A, 12OV,Lighting or Recept. .Z 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 F..r�, A HOME OWNER-BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits '^ i=I{Onrj T. Code): _�J�'1 ITEMS T y0 .. ,1 ❑ 1,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 LUTA 252 99E and Professions Cotle). I cIM(Rj CONSTRUCTION LENDING AGENCY `'gym "` 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.) - PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE candy Lender's Address Icertity a�D that 7 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 County to enter upon the above-mentioned property for inspection purposes. a ,L SEE REVERSE FOR EXPLANATORY LANGUAGE I�IUNATURE UF VLHWTTEE `� oaIE