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Home My Public Portal About10211 LA ROSA DR_Electrical__ WOR KER S'COM PENSATION DECLARATION 63 CE 806G (280) APPLICATION FOR ELECTRICAL PERMIT GRrIT , 1 hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES rr L' : BUILDING AND SAFETY insure_or a certificate of Workers'Compensation Insurance,or, a certified copy thereof(Sec. 3800,"Lab.C.) IFOR APPLICANT TO FILL IN - JOB Policy No. Company ADDRESS / G. ❑ _ New Residential Bldgs.& Pools EACH INC.I FEE Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. S — s LOCALITY ,❑ Multi-family Sq..Ft. — NEAREST n. Certified copy is filed with the county building inspection CROSS ST C� department. Residential Swimming Pools OWNER OR ;lsl • l FIRM NAME Date Applicant' - - r/(1 Outlets: Rec6ught�Sw. (a ' Go y MAIL ' First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. �� _ Additional .CITY ECI Tel No. / COMPENSATION INSURANCE - PLAN CHK d (This section need not be completed,if,the work. involved .GU - (J APPLICANT O by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First Additional S nal ADDRESS ct Total No./ r 'i 1 O -, II certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. F permit is issued, I shall not employ any person in any manner PERMIT - W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. _ APPLICANT. / / d Oven _ Dryer_W.M. ADDRESSlel - co —Date Applicant Top — FAU _W.H..— Z Hood _ Fan —Other— CITY V Tel No. - NOTICE TO'APPLICANT: If, after making this Certificate-of Disp. _ Room Air Cond.— LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. r PROCE SED BY with comply with.such provisions or'this permit shall be .deemed revoked. Size&Type HP,KW, KV A,or KVAR f0� FINAL LICENSED CONTRACTORS DECLARATION •J . . _ UP to 1 Incl. - / Over 1 to 101ncl. DATE 9 ,f'.r�/ VALIDATION Over 10 to 50 Incl I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000 of Division 3 of the'Busi- BY - < 6 ) Over 100 ness'5nd Professions.Code, and my license is in full force and effect. I _ Services License Number Lie.Class 0.200 Amp. Under 600 V 201.1 000 Amp. Under 600 V - Contractor Date Over 1000 Amp.or Over 600 V ' HOME OWNER-BUILDER DECLARATION Temp.Power Pole&'Appurtenances. -� I hereby affirmSign with One Branch Circuit. that f am exempt from the Contractor's Additional Sign,Branch Circuits - License Law for the following reason (Section 7031.5, Bus,- ° ness and Professions Code): . . 5 3 9.7 A Mist`Conduits& Conductors I, as owner of the property. will do the work and the Other (See Complete Fee Schedulel— #fiee,s e e '2 structure is not intended or offered for sale (Section _ 7044, Business and Professions Code). 2 are 2.7.4 0 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency - e e°e 2.7.4 x for the performance of the work for which this permit is PERMIT FEE (Sub-Total) ]Ty issued (Sec. 3097,Civ.CJ. yv - 0 5'217—8 1 Lender's Name - _ PLAN CHECKING FEE ,(One-Fourth Permit Fee)' r Lender's Address PERMIT ISSUING FEE - I certify that 1 have read this application and state that the TOTAL FEE above information is correct.I agree to comply with all County ordinances and State Imus regulating Electrical wiring, and ,. hereby authorize representatives of this County to enter upon , the above-mentioned property for inspection purposes. _ SEE REVERSE FOR EXP LANATO BY.LANGUAGE Signature of Permittee Date _ I WOR}KERT COMPENSATION DECLARATION 76A663 -p�+ rt - CEZ06G (2-80)• APPLICATION FOR ELE AL'PERMIT I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS A ES" f/ BUI (i.AND SAFETY ' insure, or'a certificate of Workers'Compensation Insurance,or - v a certified copy.thereof(Sec. 3800, Lab.,C.) / FOR APPLICANT TO FILL I Policy No. - Company New Residential Bldgs.&Pools EACH NO. '. FEE / -C.z` RESS Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. S — $ LOCALITY ❑ Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR l FIRM NAME Date Applicant _ Outlets: Re�-Light See. T, MI ADADLRESS C/�y�/// � ' First 20 l� CERTIFICATE Op EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Total No. CITY7Cq/n K� Additional 'n Tel No _•� } PLAN CHECK a (This section need not be completed if the work involved �C7 APPLICANT 0 by the permit is for one hundred dollars ($100) or less.) . 'Lighting Fixtures First 20 ADDRESS Additional Total No: 0 cc 1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CIT Tal No. permit isissued, I shall not employ any person in any manner - v PERMIT U so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. _ APPLICANT Lu Oven - Dryer_W.M. ADDRESS d y z, Date Applicant Top FAU _W.H.._ Hood _ Fan _Other_ CITU el No NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR ' Exemption, you should become subject to the Workers' - REG. NUMBER "Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. - PR E V with comply with such provisions or this 'permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. ' Up to 1 Incl. FINAL Over 1 to 10 Incl. GATE LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. .. VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL. _ 9 (commen cing-with Section 7000) of Division 3.Of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and - effect. - - Services /V�/ '.0.200 Amp. Under 600 V• r' License Number Lic.Class 201-1000 Amp. Under 600 V - Contractor - Date Over 1000 Amp.or Over 600 V - HOME OWNER-BUILDER.DECLARATION Temp. Power Pole& Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 70 31.5, Busi- Additional Sign Branch Circuits _ ness and Professions Code): - Misc.Conduits& Conductors - •.;2 1 '8 2 Q A al, as owner of the property, will do the work and the Other(See Complete Fee Schedule) structure is not intended or offered for sale (Section }� a -'ele.e 2 ' 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 2 ^, • 2 3.S O. I.hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit is PERMIT FEE (Sub-Total) 'e'e . 23505 issued(Sec. 3097;Civ.C.). - Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) - ,O R 2.0.!t 8 0 Lender's Address PERMIT ISSUING FEE ' I certify that I have read this application and state that the TOTAL FEE JA 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 90 enter upon _ the//above-mentji'ned prop"rt/y for inspection"purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee to '- -