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HomeMy Public PortalAbout9218 LIVE OAK AVE_Electrical__ WOt'aKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 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 ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ❑ _ $ $ LOCALITY Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. PY Y 9 P department. Multi-family Sq.FL NEAREST CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK DV.tfPAGE PARCEL 0©" OR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw._1_ IRM NAME _--� COMPENSATION INSURANCE First 20 MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS n permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting FixturesFirst 20 APPLICANT Total No. �L Additional IA J QV 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 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. LICENSOR E Over 50 to 100 Incl. REG.NUMBER BER CL Over 100 DISTRICT NO. ESSED BY O License Number Lic.Class ` V Services,Swbd.,MCC&Panelboards CJi a: Contractor Date 0-399 Amp.Under 600 V FINAL 0 DATE •� 400-1000 Amp.Under 600 V ©�G 7 VALIDATION V I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL W B.&P.C.for this reasonBRANCH 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 a SINGLE FAMILY Temp.Power Pole&Appurtenances ` HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit xs.s.�a 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 -;;- 7!L. Lf; V I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors s (tL is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 35000 and Professions Code). CONSTRUCTION LENDING AGENCY '• t •'•I�' `` t ! 1 hereby affirm that there is a construction lending agency for the -:E ifs a301 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) PLAN CHECKING FEET-;�#fids ft Lender's Name // --= PERMIT ISSUING FEE (p d Ada Lender's Address �J I certify that I have read this application and under penalty of purjury state TOTAL FEE �p 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 V �r // r/a -9 �4 /� SIGNA R E IT DATE 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. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB /1 �� ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Po Is NO. EACH FEE ❑ D� _ $ d $ 2 LOCALITY Certified co s filed with the count building inspection 1 &2-Family,Sq.Ft® l7 PY Y 9 P _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR /-� MAP BOOK PAGE PARCEL Y/ CERTIFICATE OF EXEMPTION FROM WORKERS' lg ? �--` OWNER OR Outlets:TT2!. BFt—�,_rov. / J COMPENSATION INSURANCE �" ,-� FIRM NAME G" L. * �,�_,�_j.� First 20 MAIL (This section need not be completed if the work involved by the Total No'/L_/ Additional ADDRESS permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. 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 ,r— 7 �J� Total No. T7 Additional E/E' /`i ADDRESS Date Applicant e �' 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 Vorkers'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 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. SE OR >.- Over 50 to 100 Incl. RIEGNNUMBER Class. a Over 100 DISTRICT NO. PROCESS E Y O License Number Lic.Class n y��f - V Services,Swbd.,MCC&Panelboards C/ CJ a: 0-399 Amp.Under 600 V FINAL 0 Contractor Date DATE ❑ I am exempt under Sec. 400-1000 Amp. Under 600 V I l— —�3 IU Over 1000 Am or Over 600 V VALIDATION P� FINAL a B.&P.C.for this reason BRANCH CIRCUIT FEES BY W Date: 15A,or 20A, 12OV,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 SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 6 herebyaffirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ff 25 -7�-p P S 30*7 -4 3S.,.tt . for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ITEMS EM S 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) 57 and Professions Code). t:NE_�� - r�L o.r f CONSTRUCTION LENDING AGENCY CIA 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) 23Z 4 Civ. C.) ' PLAN CHECKING FEE UIJIs)j—)�i6fu1 +��16 Lender's Name hGH 9 PERMIT ISSUING FEE � � � ��v�' �- AM Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE S-7 that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize representatives County to enter upon the above-mentioned property for insp a on purp s. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE DATE