Loading...
HomeMy Public PortalAbout9556 KENNERLY ST_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT 76A66 I Hereby affirm that I have a certificate of consent to self insure, 76A663 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 v ADDRESS ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE $ _ LOCALITY F-1 $ �i Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR G COMPENSATION INSURANCE FIRM NAME First 20 MAIL '/ E i (This section need not be completed if the work involved by the Total No. Additional ADDRESS -1 s tSN£ I-Y permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Sf�,M g: &,— Tel.No. 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 APPLICANTK 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 p y p y APPLICANT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >_ LICENSED CONTRACTORS DECLARATION ADDRESS a- I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH 8 (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 Power Apparatus&Large Appliances REG.NUMBER Class. 0 License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. G PROCESSED BV V Up to 3 Incl. �Q S UJ Contractor Date Over 3 to 10 Incl. DATE ❑ FINAL � Over 10 to 50 Incl. * n Z I am exempt under Sec. Over 50 to 100 Incl. VALIDATION Over 100 ` B.&P.C.for this reason BY Services,Swbd.,MCC&Panelboards Date: 0-200 Amp.Under 600 V Signature 201 -1000 Amp.Under 600 V 7 ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION ith Ci B with O Sign wOne Branch rcu I hereby affirm that I am exempt from the Contractor's License Law Sig �7 9� 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 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 I certify that I 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 APPLICANTTR AG DATE WORKERS'COMPENSATION DECLARATION 76A663 9DPW aie7 APPLICATION FOR ELECTRICAL PERMIT 76A66 I hereby affirm that I have a certificate of consent to self •cE-aobG insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. �.) Policy No. Company FOR APPLICANT TO FILL IN JOB l ❑Certified copy is hereby furnished. New Residential Bldgs. & C;Pools EACH NO. FEE ADDRESS C 1�� ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY NEAREST tion department. Multi-family Sq. Ft. CROSS ST. DateApplicant Residential Swimming Pools OWNER OR x' FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS gSS6 t�iJ (This section need not be completed if the work involved by CITY _ / the permit is for one hundred dollars ($100)'or less.) Total No. Additional } GI Tel. No.�." b Z1 PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. Room Air Cond. REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. P SSED BY >- and Professions Code,and my license is in full force and effect. p d Size &Type HP, KW, KVA, or KVAR +�O J 0, License Number Lic. Class Up to 1 Incl. FINAL C_J Contractor Date Over 1 to 10 Incl DATE y G ��, VALIDATION C1 ❑ Over 10 to 50 Incl. FINALF- LLJ Over 100 I am exempt under Sec. Over 50 to 100 Inc. BY G.' �µ d B.&P.C. for this reason U)Services, Swbd., MC , 7r Signature , Z Date: 0-200 Amp. Mnder 6 — Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Mains. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole & Appurtenances JL I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit 1 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& Conductors j s structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , -,•1• i Business and Professions Code). - '4 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for ".Q the s 3 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address. I certify that I have read this application and state that the I TOTAL FEE 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 spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ` A it] _ .Z. Y- y gnature of Permittee Date ©s WORKERS'COMPENSATION DECLARATION 8to/Si APPf�ICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to sCE- elf insure, CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES 'BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) Policy No. •Company FOR APPLICANT TO FILL IN - JOB .� Q Certified co is hereby furnished. EACH NO. FEE ADDRESS PY Y New Residential Bldgs.& Pools ❑ 1 & 2Family,Sq.Ft. $ _ $ LOCALITY - Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. 1 CROSS ST Date Applicaht Residential Swimming Pools OWNER OR / r • FIRM NAME`p CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. Lo ADDRESS A AIL COMPENSATION INSURANCE a ' (This.section need,not be completed itthe Work•involved by the First?_0 permit is for,one hundred dollars.($100)or less.) Total No.� Additional CITY Tel.No. 1,g that in the performance of the work for-which this permit PLAN CHECK C4 T I certify P APPLICANT 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 ' Total No. 46 Additional TeL.No. , Date Applicant Fixed Appliances Not Over 1 HPPERMIT NOTICE TO APPLICANT: If, after making this,Certificate of �cvC/ Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT provisions of the Labor Code,;you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU, W.H. CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ .I hereby affirm.that I am licensed under• provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class. Professions Code,and my license is in full force and effect. DISTRICT No. PROC SED BY Power Apparatus& Large Appliances,. _ Size &Type HP,KW,KVA,or KVAR . �(� 0 License Number Lic.Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE VALIDATION Contractor Date Over 10 to 50 Incl. O ❑ FINAL _ V I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 Services,.Swbd.,MCC& Panelboards , Z Date: 0-.200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg.Maint. Elect. 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 Misc. Conduits & Conductors the property,will do the work and the structure •:T"-.�•; is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) and Professions Code). 'Q'f_E:. .` i CONSTRUCTION LENDING AGENCY 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.). _ a j ,t PLAN CHECKING FEE Lender's Name F,• PERMIT ISSUING FEE LUL—L"011-- ^ Lender's Address ' Art f-,.,.-- I certify that I have read this application and state that the above TOTAL FEE' j � "'`'` = ="-�. 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 ature of Permittee Date