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HomeMy Public PortalAbout9923 LIVE OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 1720-0013 DPW 3/87 APPUC�AMN FOR ELEC TMICAL PERN'T I hereby affirm that I have a certificate of consent to self cE'eoec insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS akC a eefttfied copy thereof (Sec 3800, Lab C ) Policy No Company FOR APPLICANT TO FILL IN JOB / `/ 'Y/CD ❑Certified copy is hereby furnished New Residential Bldgs2& Pools EACH NO FEE ADDRESS L In� ❑Certified copy is-filed with the county building mspec- 1 & 2-Family, Sq LOCALITY Ft $ _ $ tion department Multi-family Sq FtNEAREST _ CROSS ST [IOL eFW / Residential Swimming Pools Date. Applicant OWNER OR >�. L CERTIFICATE OF EXEMPTION FROM WORKERS' RM Rec�Light�Sw r MAIL FIRM NAME C V `C Outlets COMPENSATION INSURANCE b ADDRESS This section need not be completed if the work Involved b First 20 ( p Y Total No Additional CIT C Tel No the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 d so as to become subject to the Workers'CompensADDRESS n Laws 0 ^ Additional Date ~�x_�OApplicant Total No CITY Tel No NOTICE TO APPLICANT If, afte making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Y Exemption,, you should become subject to the Workers' Range— Heater—D W APPLICATION Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W M — ADDRESSvX .S with comply with such provisions or This permit shall be Top — FAU —W H — deemed revoked Hood — Fan —Other— CITYT, ;-q,P4,5 G Tel No J0CI-1zj/ LICENSED CONTRACTORS DECLARATION Disp — Room Air Cond LICENSE OR �• I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER b p2 Class G I0 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO P S BY } and Professions Code,and my license is in full force and effect a ` / Size &Type HP, KW, KVA, or KVAR r License Number T910 6 Lic Class Cd _IQ -1 Up to 1 Inci FINAL Contractor L1110-011"'i r�_e-RMate Z Over 1 to 10 Incl DATE (� V LI ON 0 ❑ Over 10 to 50 Incl FINAL V F I am exempt under Sec Over 50 to 100 Inc BY ( W B&P C for this reason Over 100 d Serve Swbd , MCC& Panelboards D ° Z Dote 0-200 Amp Under 600 V — Signature 20 - mp Under 600 V ❑ Over 1000 Amp or Over 600 V Exemption for Reg Maint Elect SINGLE FAMILY Temp Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION L Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License !- s Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits 1 =-%l� L Professions Code) _wi T•_o�j 1 ❑ I, as owner of the property, will do the work and the Misc Conduits&Conductors f 1TEME, structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— Business and Professions Code) > TOTAL OTAL 43- 60 CONSTRUCTION LENDING AGENCY CHECK �--,•��i_j I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) t:3'if-N-K ,1141 (Sec 3097, Civ C ) PLAN_ CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address LK �( Ga�jJ I certify that I have read this application and state that the TOTAL FEE above information is correct i agree to comply with all County ordinances and State jaws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the ove-mentioned pro erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ure Permittee ©$ Date WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 O affirm that'l have a certificate of consent to self 117 e663c - APPUC AIROH FOR ELECTUCAL PERM ' insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec 3800, Lab C ) Polici;No Company FOR APPLICANT TO FILL IN JOB 0 Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS q q�f!.i 3 t I V4, QCertified copy is filed with the county building inspec- 1 &•2-Family, Sq Ft $ — $ LOCALITY tion department Multi-family Sq FtCROSSSST Date Applicant Residential Swimming Pools OWNER OR FIRM NAME g. IE e4 (fu I fZ. CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec-9—Light<Sw MAIL COMPENSATION INSURANCE ADDRESS a (This s need not be completed if the work involved by CITY rjp! yy� Tel No the permmitit I Total No Additional 20 s for one hundred dollars ($100)or less.) ional PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit 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 x �'F Additional Date Applicant &'4,.e_-1,w&'4,.e_-1,wTotal No CITY Tel No NOTICE TO APPLICANT/If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT- Exemption, you should become subject to the Workers' Range— Heater—D W — APPLICATION ��C Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W M — ADDRESS 10 l(� with comply with such provisions or this permit shall be Top — FAU —W H — deemed revoked Hood — Fan —Other_ CITY CoV� UCL � g1j'aTel No I LICENSED CONTRACTORS DECLARATION Hoo OR Disp — Room Air Cond — 1 hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER -!5'619 4Z Class G"10 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PR SED BY >_ and Professions Code,and my license is in full force and effect - D_ Size&Type HP, KW, KVA, or KVAR ,T/ O License Number h Jr%�'� LIC Class Up to 1 Incl FINAL G� U Contractor C��Qn© � Date �' _V' Over 1 to 10 Incl DATE �lQ ' // VALIDATION 0 OOver 10 to 50 InFINAL ( ,p F- I am exempt under Sec Over 50 to 100 Inc By r�-/7r-Z� U Over 100 LU B&P C for this reason d D Date Services, Swbd , MCC& Panelboards 0 Z -200 Amp Under 600 V Z— Signature 201 - 1000 Amp Under 600 V Over 1000 Amp or Over 600 V Exemption for Reg Malnt Elect SINGLE FAMILY Appurtenances Pole &A Power.. pp HOME OWNER-BUILDER DECLARATION i 1 hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits Professions Code) 3,'_G 7 Mlsc Conduits&Conductors i T rte: 1, as owner of the property, will do the work and the structure Is not Intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ D Business and Professlons.Code) TOTAL _„_, i_'i CONSTRUCTION LENDING AGENCY E_� 1�! I hereby affirm that there Is a construction lending agency foryi{71 +c !F! the performance of the work for which this permit Is Issued PERMIT FEE (Sub-Total) - - (Sec 3097, Civ C ) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE L. h Lender's Address r D -r`t 1 AM i'_!:•_1 I certify that I have read this application and state that the TOTAL FEE 3�7 above Information Is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize repre tatives of this County to enter upon thea ave-mention operty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Slgnatu of Permittee Date i