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Home My Public Portal About9223 LEMON AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 76A663 — I hereby 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 therbbf,(Sec ADD Lab C) Policy No Company FOR APPLICANT TO FILL IN JOB ADDRESS 0 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 departmentMulti-family Sq Ft NEAREST CROSS T Date! Applicant Residential Swimming Pools + ASSESSOR Q PARCEL Q�f MAP-BOOK p1 4f PAGE CERTIFICATE OF EXEMPTION FROM WORKERS' rl a OWNER OR COMPENSATION INSURANCE Cutlets RBC Light Sw /J FIRM NAME ' First 20 d �T (This_sectlon need not be completed if the work involved by the MAIL permit is for one hundred dollars(5 100)or'less) Total No Additional ADDRESS ' I certify that in the performance of the work for which this permit CITY o z is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject,to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No Additional ADDRESS Date -,Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP 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 forthwlfh comply with such PERMIT- r 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 affiin 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 Over 50 to 100 Incl LICENSE OR Class REG NUMBER Q. Over 100 DISTRICT NO PROC SSED BY O License Number Llc Class 9� V Services,Swbd,MCC&Panelboards Q�// cc Contractor Date 0-399 Amp Under 600 V DATE FINAL O 400-1000 Amp Under 600 V 227 VALIDATION V I am exempt under Sec Over 1000 Amp or Over 600 V FINALLLI a, B&P C for this reason BRANCH CIRCUIT FEES BY Uj Date 15A,or 20A, 120V,Lighting or Recept Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuits ` Exemption for Reg Malnt Elect 15A,20A,208V To 277V Lighting Br Circuits 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 5� Code) 0 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) r Civ C) l>. PLAN CHECKING FEE - - _ ; Lender's Name PERMIT ISSUING FEE76 Lender's Address 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 ordm and State laws regulating Electrical wiring,and hereby authorize res tatives of this County to enter upon the above-mentioned property ASIGIIPO ctlon osesSEE REVERSE FOR EXPLANATORY LANGUAGE E OF PE E DATE - WORKER'S COMPENSATION DECLARATION 200019 DPW(12-91) 76A663 APPLICATION FOR-ELECTRICAL PERMIT I hereby affirm ttiat.l have a certificate of,consent to self Insure, , � or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOSANGELES ''' DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV copy ther6of.(S�e+cr+ADD Lab CC Policy No l 2f�you-�nmpany FOR APPLICANT TO FILL IN JOB F-1l - ADDRESS 0. O(JV Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE LOCALITY EDCertified1 &2-Family,Sq Ft — $ $ Certd copyos filed with the unty building inspec On NEAREST 1r�department Multi-family Sq Ft CROSS ST k 1�R Residential Swimming Pools ASSESSOR Date `gG�pplicant 4^-* tMAPBOOK _ � PAGE PARCEL , CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec 13L Light Sw * I,IFIPM NAME 00 qp6)Qnf_- COMPENSATION INSURANCE ` O o ..--r First-20 AIL (This section need not be completed if the work Involved by the 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 ti CITY No is Issued, I shall not employ ariy person in any manner so as t0 PLAN CHECK (��J becomeisubject to the Workers' Combansation Laws Lighting Fixtures^ First 20 APPLICANT p r� Total No 5• , Additional, ADDRESS Date• 1047' `T 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 revisions of the Labor Code, you must forthwith-com I with such PERMIT p p y Power Apparatus&Large Appliances APPLICANT ' provisions or this permit shall be deemed revoked � �y • LICENSED'CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS a f 9 3 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 No Professions Code,and my license is in full farce and effect Over 10 to 50 Incl } LICENSEX1 Over 50 t0 100 Incl �i REG NUMBER '7 7,77 Class- - a ,L" L Over 100 - j DISTRICT NO - PROC SED BY Q License Number �V �i i Lic Class�_ �D r� ��s (� Services,Swbd,MCC&Panelboards U (�L Contractor ate u/` "` 0-399 Amp Under 600 V FINAL DATE Q ❑ I am exempt under Sec 400-1000 Amp ,Under 600 V Z�Z Z-(� Over 1000 Amp or Over 600 V FINAL VALIDATION d B&P C for this reason BRANCH CIRCUIT FEES BY (n to 15A,or 20A,120V,Lighting or Recept Z_ 1 To 10 Branch Circuits Signature o 11 To 40 Branch Circuits 41 Or More Branch Circuits - ❑ Exemption for Reg •Mamt Elect 15A,20A,208V To 277V Lighting Br Circuits SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit , r I hereby affirm that I am exempt from the Contractor's License Law gj-� for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits Code y irE .. ❑ I, as owner of the property,will do the work and the•structure Misc Conduits&Conductors, 83 - !5'5 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)' J/ Civ C) if ' r�IM PLAN CHECKING FEE ` Lender's Name PERMIT ISSUING FEE 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 4repr tatives oft is County to enter u on the above-mentioned property r I ection p ses SEE REVERSE FOR EXPLANATORY LANGUAGE R DATE ' WORKER'S COMPENSATION DECLARATION 9 DPW c,2-9,> 76A66APPLICATION FOR ELECTRICAL PERMIT 76A663 I hereby%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 theiedf,(Sec t800 Lab-16 Policy No FOR APPLICANT TO FILL IN _. JOB ❑, NO FEE ADDRES Certified copy Is hereby'fumished ,EACH _ New Residential Bldgs &Pools •LOCALITY ElC1 &2-Family,Sq Ft — $ $ ertlfled copy is filed with the county budding inspection NEAREST departmentMulti-family.Sq Ft CROSS ST _r • Date •' F• r • ' Applicant Residential Swimming Pools - ASSESSOR MAP BOOK - PAGE PARCEL s CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR Outlets Rec _Light Sw - FIRM NAME ' COMPENSATION INSURANCE * J+ First 20 (This section need not be'cADDRESS =.ompleted If the work Involved by the MAIL `7.0 Total No Additional I' " permit Is for one hundred dollars(5100)•or less) � - � I certify that in the performance of the 'work for which this permit CITI �`�J Tel No4q.;Gl6 is issued, I shall not employ any-person in 'any manner so as to become sub ect to,the'Workers' Com ensation Laws Lighting Fixtures First 20 PLAN CHECK 1 f p _ 9 g APPLICANT Total No Additional " ADDRESS ' Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO.APP,LICANT• 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`perriit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT �7eee - i., . `" -LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby0affirm'that•1 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 licenss'is in full force and effect Over•10 to-50 Incl } - Over 50 to 100 Incl REG NNUMBER ' Class a License Num In tncu Over 100 - DISTRICT NO ED BY O Services,Swbd,MCC&Panelboards �(JO • j�yr[ L� 0-399 Amp Under 600 VDATE ` to O ❑ I am exempt under Sec 400-1000 Amp Under 600 V —�� VALIDATION W Over,1000 Amp or Over 600 V FINAL B&P C for this reason BRANCH CIRCUIT FEES BY Z Date 15A,or 20A, 120V,Lighting or Recept _ 1 To 10 Branch Circuits ature -• 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 ' q- HOME OWNER-BUILDER DECLARATION JL Sigh with One Branch Circuit „�'�' " - 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 L 3307 59.71 Code) - id ITEMS' ❑ I, as owner of the property,wlll•do the work and the structure MI 1 sc Conduits&,Conductors v is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL !t-9 - 55 and•Professions Code) " r►j�/ CONSTRUCTION LENDING AGENCY _ 1'`hereby affirm that there Is a construction lending agency for the �•ftt'tl'Gf{,,AA��{'E vut-I performance of-the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub-Total) Civ C) D - s PLAN CHECKING FEE (��_ i 11/ 2/9 Lender's Name PERMIT ISSUING FEE vZ 6442 1, Aid- it:', Lender's AddressTOTAL FEE l� I certify that I have read this application and under penalty of puqury state ,! that the above information is correct I agree to comply with all County - ordinances and State laws regulating Electrical wiring,and hereby authorize representati Of this County to enter upon th above-mentioned property for ctio purposes SEE REVERSE FOR EXPLANATORY LANGUAGE !!!Z- _ SIGNATURE OF PERMITTEE DATE ,