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Home My Public Portal About9216 LIVE OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION -663 10/81 CE-Bose APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, CE -806G or a certificate of'. /orkers' 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 '/ E] LV.Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS I , of K. ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY G Certified copy is filed with the county building inspection Ty department. O Multi-family Sq.Ft. — NEARESTT. (�f�, rC CRSS S Date Applicant Residential Swimming Pools OWNER OR FIRM NAME :E. CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:Rec Light2-3- 2 /yE �ov 45 ADDRESS (This section need not be completed if the work involved by the First 20 Total No. Additional CITY Tel.No. l2� permit is for one hundred dollars($100)or less.) PLAN CHECK I certify that in the performance of the work for which this permit 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 ' 2 Additional Total No. Z? - CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of � J 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 _L Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top FAU W.H. CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood Fan -2— Other_ I hereby affirm that I am licensed under provisions of Chapter 9 �, LICENSE OR Disp. Room Air Gond.. REG.NUMBER Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. p PROCESSED BY Size& Type HP,KW,KVA,or KVAR �a License Number Lic. Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE ��Z�J' fx' Contractor DateVALIDATION O ❑ Over 10 to 50 Incl. FINAL r ~ I am exempt under Sec. Over 50 to 100 Inc. gY L d B.&P.C.for this reason Over 100 N' Services d;,MCC&ParnelboaVrds Z Date: 0- 00 t UndeSignature 201 - 00 Amp.Une ❑ Exemption for Reg. Maint.,Elect. Over 1000 Amp.or Over 600 V 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 y for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits y':`: ,ir Code): I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors ! t°t 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 j� I it l i-[li ff.Ex j vi ,`* PERMIT ISSUING FEE 1=:-- Lender's AddressC� r- -, --. I certify that I have read this application and state that the above TOTAL FEE ` a '� 1 AMI�0` ' 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 propertyfo�ir5e�U3n p Fpo S. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa ermi to Dat 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 thereof(Sec.3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB l J/_ /9 �• ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY �! , E 67- ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST t' department. Multi-family Sq.Ft. CROSS ST. Al Date Applicant Residential Swimming Pools ASSESSOR / MAP BOOK ( PAGE S-71PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR Cutlets:Rec._Light Sw. , COMPENSATION INSURANCE First 20 tyleraw�tote (This section need not be completed if the work involved by the MAIL permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS I certify that in the performance of the work for which this permit CITY ✓�� ' I r Tel.No is issued, I shall not employ any person in any manner so as to PLAN CHECK �4! 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 forthwith comply with such PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 14ij-t 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. } LICENSE OR Class. d Over 50 to 100 Incl. REG.NUMBER Over 100 DISTRICT NO. PRQCESSED BY O License Number Lic.Class V Services,Swbd.,MCC&Panelboards �� „l—> cc Contractor Date 0-399 Amp.Under 600 V FINAL DATE 0 El 400-1000 Amp.Under 600 V VALIDATION I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL W B.&P.C.for this reason BRANCH CIRCUIT FEES BY Date: 15A,or 20A, 120V,Lighting or Recept. �( (p�� Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El Exemption Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 7 SINGLE FAMILY Temp.Power Pole&Appurtenances Q HOME OWNER-BUILDER DECLARATION - s I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit1- ) o for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ;'x,`07 H 65°'71; I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors 1 i)E'fes` is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 5 and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 6`=o{I0 1 hereby affirm that there is a construction lending agency for the Ci"tANIGE .00 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) 17 PLAN CHECKING FEE Z){ E ()_ ji -' 0 S%111 :L Lender's Name 4 PERMIT ISSUING FEE p? t�.618 1 AM11:01 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 fo�insn purpos SEE REVERSE FOR EXPLANATORY LANGUAGE SI E OF P MI EE / DATE