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Home My Public Portal About9823 HOWLAND DR_Electrical__ "WORKER'S Ihave COMPENSATION DECLARATION 2x663 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT I•hereby affirm that I have a certificate of consent to self insure, 76A663 or a certificate at 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.)-, :1. Policy No. Company FOR APPLICANT TO FILL IN- - JOB p AOORESS X23 N'-r .A PF.�_ T• C- Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ❑ $ _ $ LOCALITY 'Certified copy is tiled with the county building inspection . - 1&i--Family,Sq.FL NEAREST department. Multi-family Sq.Ft. CROSS ST, ' Date - Applicant Residential Swimming Pools ASSESSOR MAP BOOK I PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:Rec. Light Sw. _ FIRM NAME l� N First 20 MAIL (This section need not be completed if the work involved by the ADDRESS permit is for one hundred dollars($100)or less.) Total No. Additional - I2'$ V�-. , 3 Carl that in the performance of the work for which this permit CITY x� (�� Tel No. 4213 is issued. shall not employ any person in any roan ner so as to - iTIAIN become subject to the Workers'Compensation Laws. ., Lighting Fixtures First 20 APPLICANT K Total No Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of � � CITY Tel No. Exemption,,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with.such 11 TO 40 INCLUSIVE EACH PERMIT provisions or this parmit shall-be deemed revoked. APPLICANT P - 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS � I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 27TV LIGHTING EACH O (commencing with Section 7000) of Division 3 of the Business and CITY Tel,No, U Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR cc Power Apparatus&Large Appliances REG.NUMBER Class. d License Number Lia Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. p PR%SF.SSED BY Up to 3 Incl - eSo p a Contractor Date Over 3 to 10 Incl. FINAL fn ❑ - Over 10 to 50 Incl. "' VALIDATION DATE ? I am exempt under Sec. Over 50 to 100 Incl. Over 100 _ - FINAL } 8.8P.C.for this reason BY Services,Swbd.,MCC&Panelboards_ ,T Z. Dale: 0-200 Amp.Under 600 V r) � � Signature - - 201 -1000 Amp.Under 600 V �r ^ C,. ❑ _ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. _ J . SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION I 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 - 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) Opp. and Professions Code). , 6^ F. CONSTRUCTION LENDING AGENCY _ ' ' 1 .( :"iii 9 a=� 1 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 Lender's Address FEE g I certify that 1 have read this application and state that the above TOTAL3- information is correct. 1 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 - propert for' spection aees� SEE REVERSE FOR EXPLANATORY LANGUAGE SIGN R FAPPLICANT OF AGENT 0 LATE WORKER'S COMPENSATION a ENSATION of consent to 20 0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT Ll 60663 I hereby affirm that I have a certificate of consent to sell insure,or a c6rtificate 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. gC.)� �{j/� /,/�/J POIICy Nn�/��Z 7C.01'�rlpanPJ�F/'� � —�' FOR APPLICANT TO FILL IN JOB �fj. , i__ Lost'). `� yin �x� ADORES$ Z J RCxzJ L,p� W ❑ ' Certified copy is hereby furnished. ��4Aap New Residential Bldgs.&Pools NO. EACH FEE LOCALITY .to ❑ Certified copy is filed with the county ui ld ing' spection 1 &2-Family,Sq. Ft., j-�_ — $ NEnREST department.q Multi-family Sq.Ft. CROs , t IJ Date 8/ pplicant Residential Swimming Pools ASSESSOR MAP BOOK 9 pgGE PARCEL"'ti CERTIFICATE OF E%EM PTION FRA WORKERS' OWNER OR COMPENSATION INSURANCE Gutlats:Rec._Light Sw._ FIRM NAME JQ\ T First 20 MAIL _ e (This section need not be completed'if($100 the work Involved by the Total No. Additional ADDRESS "LJ�' S� IN GC( permit is for'one hundred dollars(5100)or less.) I certify that in the performance of the work for which this permit CITY CA TO,Na, IS issued, I shall not employ any person In any mapper so as to PLAN CHECK becomesubject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant - NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP'. 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 provisions or this permit shall be deemed revoked. Power,Apparatus&Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW.KVA,or KVAR ADDRESS ZZ ee=T 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 CITYf�OIA iel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. } LICENSE OR 32_5 p Class Over 50 t0 100 Incl. REG.NUMBER J Q O� di d r (�,7 ,(Q Over 100 DISTRICT NO. PRO ESSEO BY 0 License Number SL.�i�/ Lic.Class p U Services,Swbtl.,MCC&Panelboards I Oil Q Contractor 1'�'�9i-� '�"- Date - �'�� 0-399 Amp.Under 600 V 1 FIATS n O ❑ 400-1000 Amp.Under 600 V 9-Z -'1 VALIDATION U I am exempt under Sec. IL d Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY Tn Date: 15A,or 20A, 120V,Lighting or Recept. Z I To 10 Branch Circuits Signature 11 To 40 Branch Circuits a ❑ 41 Or More Branch Circuits Exemption for Reg.Maint. Elect iSA,200,208V To 277V Lighting Br.Circuits SINGLE FAMILY +^S 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 AGGT.i for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits .57 Code). JJO7 J.;9 r ❑ I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors - 1 ITEMS is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)_ • and Professions Code). CHECK 339. 57 CONSTRUCTION LENDING AGENCY CHECK 3-69.J( I hereby affirm that there is a construction lending agency for the CHANGE .QQ performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Suh-Total) /� Civ. C.) PLAN CHECKING FEE Lender's Name ffn nn VUl V-1V V nnnri 1 11/13/9 PERMIT ISSUING FEE Lender's Address 6561 1 AN u.fti 1 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 County to enter upon the above-mentioned property for inspect SEE REVERSE FOR EXPLANATORY LANGUAGE ' SIGNATUn P PERMITT DATE