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Home My Public Portal About10546 LIVE OAK AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT 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 thereof(Sec 3800L ybF/A7C) /►/q��( .,iryt Policy No i I �I Company FOR APPLICANT TO FILL IN El Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE LOCALITY (.E G—e Certified copy is filed with the county building pecti 1 &2-Family,Sq Ft _ $ P� NEAREST depart ent Multi-family Sq Ft CROSSST �,L MON T Date Applicant ' Residential Swimming Pools ASSESSOR t MAP BOOK PAGE I Z PARCEL Z CERTIFICATE OF E ION FROM WORKERS' Outlets Rec _Light Sw FD�RM NAME c/ �TS irL, COMPENSATION INSURANCE First 20 MAIL (This section need not be completed the work Involved by the Total No Additional ADDRESS6,:5> U O-A 4 permit is for one hundred dollars($1000)or less) ' I certify that in the performance of the work for which this permit CITY toTel No is Issued, I shall not employ any person In any manner so as to PLAN CHECK C become subject co 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 forthwith comply with.such 7 PERMIT �^ provisions or this pert shall be deemed revoked Power Apparatus&Large Appliances APPLICANT miU l.� LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS r14,5:7? K106 41/V/doo I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl CITY �/ MQ� Tel No ��Q 3� (commencing with Section 7000) of Division 3 of the Business and S, G, Professions Code,and my license is in full force and effect Over 10 to 50 Incl >_LICENSE OR Cl /U+ Over 50 10 100 Incl REG NUMBER ass a License Number 5/049/ 7 LIC Class (l Over 100 DISTRICT NO �f PROCESSED BY C) Services,Swbd,MCC&Panelboards �'�1�OVUM^/' 0 399 Amp Under 600 V FINAL O Contractor ate - DATE /J I— ❑ I am exempt under Sec 400-1000 Amp Under 600 V -({7-9j VALIDATION LU Over 1000 Amp or Over 600 V FINAL d 8&P C for this reason BRANCH CIRCUIT FEES BY / Date 15A,or 20A, 120V,Lighting or Recept d�Y Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits F-141 Or More Branch Circuits Exemption for Reg Maint Elect 15A,20A,208V To 277V Lighting Br Circuits SINGLE FAMILY Temp Power Pole&Appurtenancesypq, HOME OWNER-BUILDER DECLARATION CTas I hereby affirm that-1 am exempt from the Contractor's License Law Sign with One Branch Circuit tIG for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits i 3-307 250.65Code) _ _ _ ._ _-1 El1, Conduits&Conductors ITEMS I, as owner of the property,well do the work and the structure d� is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TIJTAL 250® 65 and Professions Code) CHECK ?� a6` CONSTRUCTION LENDING AGENCY u (• 1 hereby affirm that there is a construction lending agency for the CHANGE .10 performance of the work for which this permit is Issued (Sec 3097, PERMIT FEE (Sub-Total) a Civ C) PLAN CHECKING FEE 11020-0001 3/19/93 Lender's Name PERMIT ISSUING FEE �� 7U Ao2r 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 Iio pur ses g SEE REVERSE FOR EXPLANATORY LANGUAGE S NATUR PER ITTEE DATE WORKER'S COMPENSATION DECLARATION 20-0079 DPW(72-97) ��®� ®� �� PERNT Y 76A663 - tldtl o �f 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 thereof(Sec 3800 Lab C) JOB P011cy N6 Company v49��/�/ FOR APPLICANT TO FILL IN ADDRESS d / r" ' VL CJp ❑ Certified copy Is'hereby furnished ` 7/j New Residential Bldgs &Pools NO EACH FEE 1; — $ � LOCALITY l�l"L L� G 1 T' Certified co is filed with the count building inspection 1 &2-Family,Sq Ft PY Y 9 P NEAREST department Multi-family Sq Ft CROSS ST Date = Applicant __S - Residential Swimming Pools M PEBOOK PAGE PARCEL CERTIFICATE OF EXEMPTION F WORKERS' Outlets Rec _Light Sw FIR NNE'AME ' COMPENSATION INSU NCE _ b L �' ,d. t V d First 20 MAIL (This section need not be completed If the'work Involved by the Total No Additional ADDRESS ()Vv permit'is for one hundred dollars'(000)or less.)' . I certify that in the performance of the work for which this permit CITY-re.`r•7L� Gf = Tel No 2— 6 is Issued, I shall not employ any person in any'manner so as t0 PLAN CHECK become,sublect to the Workers'Compensation Laws Lighting Fixtures First 20 APPLICANT To Total No Additional i ADDRESS �l V S� 6,A F3R fE F3L C> Date Applicant NOTICE TO APPLICANT If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP CITY J t Tel No Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP rovisions of the'Labor Code, ou must forthwitli com I with such PERMIT p Y p y Power Apparatus&Large Appliances APPLICANT u ./ provisioris-or this permit shall'be deemed revoked ' LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS i .1 12 t ` {j LVA 1'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,S� TO No Z� _ Professions Code,and my license Is In full force and effect Over 10 to 50 Incl LICENSE ORClassri Over 50 to 100 Incl REG NUMBER p o+ O 1 Over 100 DISTRICT NO PROCESSE License Number?�[�� Lic Class V TES Totem) Gc fJ�T Services,Swbd,MCC&Panelboards - c I ? 0-399 Amp Under 600 V O Contractor DATE ❑ I am ex under Sec 400-1000 Amp Under 600 V 3—Z(L W // VALIDATION Over 1000 Amp or Over 600 V FINAL a B&P C or this reason BRANCH CIRCUIT FEES BY Date 15A,or 20A, 120V,Lighting or Recept Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg Maint Elect 15A,20A,208V To 277v Lighting Br Circuits 2 SINGLE FAMILY TPower o e&Appurtenances 7-1 AUT s HOME OWNER-BUILDER DECLARATION A�� t °E I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch"Circuit �� for the following reason (Section 7,031 5, Business and Professions Additional Sign Branch Circuits - x 3017 u•_°v Code) - i T C ❑ _ - - -- - 1 1�Ca I, as owner of the property,well do the work and the structure Misc Conduits&Conductors A �•� .Q.d••� Is not Intended or offered for sale (Section 7044,.Business Other(See Complete Fee Schedule) T TNL E, a -I., and Professions Code) Ct�fldf_ry°vtf ��•�i CONSTRUCTION LENDING AGENCY -- -- - -- - - CHANGE .03 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 'p0l(�-Q[I[ii x./ 4/93 Lender's Name d -1 All 3:51 PERMIT ISSUING FEE Lender's Address o I Certify that I have read this application and under penalty of purjury state TOTAL FEE CJ Q 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 Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 3 1 -SIGNATUR ERMITTEEERMITTEE DATE