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HomeMy Public PortalAbout6014 KAUFFMAN AVE_Electrical__ CORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm,that I have a cartificate of consent to self insure, 76A663 or p 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 El ADDRESS 0/44 (Z1d. ha' . ✓� Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ❑ o'�ty — $,12-:7- $ LOCALITY y/Q. ✓ G Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. dedepartment, Multi-family S Ft. NEAREST P Y q CROSS ST. --W Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK PAGE V / PARCEL CERTIFICATE OF-EXEMPTION FROM WORKERS' Outlets:Rec._Light OWNER OR COMPENSATION INSURANCE g Sw. FIRM NAME First 20 (� (This section need not be completed MAIL .the work involved by the Total NoAdditional ADDRESS 66/2 KasL ' N1cSH �Y� permit is for one hundred dollars($100)or less.) o- I certify that in the performance of the work for which this permit CITY ',gym Ci CA Tel.NcC�/8)�p —® is issued, I shall not employ any person in any manner so a3 to ALAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date� � Applican NOTICE TO APPLICANT: If, after making this-Cert' icate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No. Exemption,you should become subject to the Workers' mpensation 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 l,L(;7 1©g o. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS s t� a 13 k Oyp ✓2 I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. S r e 2 f Q (commencing with Section 7000) of Division 3 of the Business and CITY (1Q 4 c Tel. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. 7.11 Over 50 to 100 Incl. LICENSE OR /� Class. REG:NUMBER ,y r+®� C JO 0- License Number V Lic.Class _/0 Over 100 DISTRICT NO. P O SED BY O `` J Services,Swbd.,MCC&Panelboards Contractor (i1Q ZA oo A Date .S r 3 J J 0-399 Amp.Under 600 V FINAL DATE El 400-1000 Amp. Under 600 V 7 I am exempt under Sec. VALIDATION Over 1000 Amp.or Over 600 V FINAL ) W B.&P.C.for this reasonBRANCH CIRCUIT FEES By (a Date: 15A,or 20A,120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances -' L r� a HOME OWNER-BUILDER DECLARATION ACC a4 I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit �� ^,;•kms for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ,3907 �=f�`O�� Code): 1 ITEC ❑ 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) TOTAL 223. 47 and Professions Code). '�t-` CHECK 226.4'7 CONSTRUCTION LENDING AGENCY ,IXI CHANGE 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.) ''t i 1 PLAN CHECKING FEE woo-cool 2I 93 Lender's Name 1 PERMIT ISSUING FEE �7'jl 7944 1 AM11:05 Lender's Address � - -- _._ I certify that I have read this application and under penalty of purjury state TOTAL FEE +g t-Z-7 that the above information is correct. I agree to comply with all County O� ordinances and State laws regulating Electrical wiring,and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. 9j SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATR O -R I 'E DATE WORKER'S COMPENSATION DECLARATION 720-0019 6A663 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT he affirm 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.) c Policy N0.• Company FOR APPLICANT TO FILL IN JOB O ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ❑ _ $ $ LOCALITY Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. p Multi-family Sq Ft. NEAREST department. CROSS ST. Date , D Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. OWNER OR COMPENSATION INSURANCE E First 20 FIRM NAME: AMW L�L_ (This section need not be completed if the work involved by the MAIL 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 Tel.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK 7 become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional /m� _ �f�, f ADDRESS Date Applicant RENTI L PPLIANCES NOT OVER 3 HP. / !O 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 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 Over 3 to 10 Incl. (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 Incl. OLICENSE B Class. } Over 50 to 100 Incl. REG.NUMBER a- License Number Lia Class Over 100 DISTRICT NO. PROCESSE O ` ,n V Services,Swbd.,MCC&Panelboards J ^v cc Co t ctor Date 0-399 Amp.Under 600 V FINAL DATE 9-13-13 0 I am exempt under Sec. 400-1000 Amp.Under 600 V VALIDATION Over 1000 Amp.or Over 600 V FINAL UJ d BRANCH CIRCUIT FEES B.&P.C:for this reason BY / p Z ate: ! 15A,or 20A,120V,Lighting or Recept. � � Z_ l 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuits Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances y-. HOME OWNER-BUILDER DECLARATION A-1C •Inv I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit aa for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 70-3 61.N Code): ❑ I ITEMS I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors 'i• -fi •�, is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I t t��i .5- -> and Professions Code). pool. CHECK CONSTRUCTION LENDING AGENCY • >HAM E `. f 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 I.II �III-000, Li 18. 9 Lender's Name �� �;*­0F_!i PERMIT ISSUING FEE 0343 �• °;=IF_=' Lender's Address I 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 ins coon pu p ses. UAA---- G /�_ 9. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNA RE OF PERMITTEE DA1FE