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HomeMy Public PortalAbout6418 LIVIA AVE_Electrical__ 11 ,WORKERS'COMPENSATION DECLARATION 76A663 10/81 B A �p ® q p �/� f I hereby affirm•that I have a certificate of consent to self Insure, CE-806G APPUCy6i1MON FOR ELECT QCB•• L PE�$N tl or a certificate of Workers' Compensation Insurance, or a certifiedCOUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof,(Sec 3800,Lab C) . Policy No Company ' FOR APPLICANT TO FILL IN - JOB f �' ❑ ADDRESS Certified copy is hereby furnished New Residential Bldgs & Po I EACH NO FEE © 1 & 2-Fam $ _ $ LOCALIT,Y:,', Certified copy is filed with•the,county budding inspection ily,Sq Ft department'+`• ' t • + k Multi-family Sq,Ft CROSS SST �j% • f p,�, j , ) Residential Swimming Pools ' OWNER oR - Date Applicant �` Outlets Rec SRM NAME Light Sw �+4 VZ A, a CERTIF,ICAT,E,& EXEMPTION FROM WORKERS'' Outlets � MAIL •. •• , COMPENSATION INSURANCE r • �• O Ll J J sw,ADDRESS This,section need not lie completed if the work Involved First 20 ( b P Y the CITY'— Tel No perm+t,Is for�one hundred dollars ($100),oi,less) Total No Additiorial r -..I certify that in the performance of the work for which this permit PLAN CHECK, Is Issued, I,shall••not employ an • APPLICANT y person in,any manner so as,to s become subject to' m Workers'.the Work 'Copensation Laws• Lighting Fixtures First 20 (� ADDRESS - "' S Total'No W- AdddionaP f CITY-' _ Tel No Date' Applicant Fixed Applia es Not Over,1 HP NOTICE TO APPLICANT If, after 'making this Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range Heater_ DW provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer — ,W M %�,�� .7 ADDRESS �, ,�OtF 0,3 provisions'or this permit shall be deemed revoked Top, 'FAU WH LICENSED CONTRACTORS DECLARATION CITY Tel No Hood Fan Other_ 3556 , Lhereby affirm that'I am licensed under.'provisions of,Chapter 9 LICENSEoR Disp — Room Air Cond _ 5 S7 Class (commencing with Section 7000) of Division 3 of the Business and REG NUMBER Professions,Code,and my license is in'full force'and effect DISTRICT NO P SED eY : _Power Apparatus& Large Appliances �/ �f C ` Size&Type HP,KW,KVA, or KVAR Ip �/L U �i - License Number^7 / ✓'Z4 Lic Class Up to 1 Incl FINAL '�,J,, C Over 1 to 10 Incl DATE VALIDATION Q. 'Co ntractors"'� s�R3I~ e J- /S' - ❑ e 'Over 10 to 50 Incl FINAL V I am exempt under Sec Over 50 to 100 Inc BY ai B&PC for this reason Over 100 Services,Swbd,MCC&-Panelboards. D Date ra 0-,200 Amp Under 600 V,•F f7� Signature 201 -;1000 Amp•Under-600 V - ACCT -n - ❑ - Over 1000 Amp or Over 600 V• r f Exemption for Reg Maint Elect ,` r SINGLE FAMILY- ":' Temp_ Power Pole& Appurtenances` 33�' 170 40:: HOME OWNER-BUILDER DECLARATION` Sign with One Branch Circuit 1 I IG�fph7—y I hereby affirm that I am exempt from the•Confractor's Licehse Law. Additional;Sign Branch Circuits , _• TOTAL,_ _ - st for the'following reason(Section 7031 5,Business and Professioris•• a Code) 1 ❑ Mlsc Conduits&Conductors - - CHECK ,• 1!5.40 I,as owner of the property,will do the work and the structure CHANE o00 is not intended or offered.for sale (Section 7044, Business Other(See Complete Fee Schedule) D and Professions Code) CONSTRUCTION LENDING AGENCY - - 0 —QQ01 g/17/ 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) Q 15',. _ 11. ,AM10 49• Civ C) PLAN CHECKING FEE t° ' Lender's Name PERMIT ISSUING FEE pO Lender's Address / I certify that I have read this application and state that the above, TOTAL FEE information Is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize resentatives of this County to enter upon the above-mentioned p erty for S b O urpo S SEE REVERSE FOR EXPLANATORY LANGUAGE Slg ture of Permitteb Date WORKER'S COMPENSATION DECLARATION 200019 DPW 9/89 p I�R9p ��pP9��®Itl ®� ELECTRICAL IT��ItlI� tl - • 76A663 P�41T P L I hereby affirm dhat I have a certificate of consent to self Insure, or a c2rtificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV c6py thereof(Sec 3800 Lab C) Policy NO Company FOR APPLICANT TO FILL IN" - JOBy� i ' ADDRESS ;0 /_III, / ❑ Certified_copy is hereby furnished New Residential Bldgs &Pools EACH NO- FEE ❑ $ _ $ LOCALITY _ G Certified copy is filed with the county budding Inspection 1 &2-Family,Sq Ft department Multi-family Sq Ft CROSS s7 ` r M IQ 4P r Date Applicant' Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF,EXEMPTION FROM WORKERS' Outlets Rec —Light Sw OWN NAME COMPENSATION INSURANCE First 20 FIRMMAIL (This section need not be completed If the work involved by the Total No Additional ADDRESS /7I permit is for one hundred dollars($100)or less.) I certify that In the performance of the work for which this permit CITY 67 Tel No r is issued, I shall not employ any person In any manner so as to PLAN become subject to the Workers' Compensation Laws Lighting Fixtures First 20 APPLICANT CHECK Total No Additional �A 2_' ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS " NOTIC TO APPLICANT If, after making't Is Certificate o - CITY Tel No Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must-forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT APPLICANT provisions or this permit shall be deemed revoked 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS / a I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH (commencing with Section 7000) of Division 3 of the Business andCITY Tel No �!f 0 Professions Code,and my license is In full force and effect RESIDENTIAL APPLIANCES UP TO 3HP LICENSEClass C—/Q 0 7 /� Power Apparatus&Large Appliances _REG NUMBER -O License Number 3 �Llc Class V Size&Type HP,KW,KVA,or KVAR DISTRICT NO �� may` PROCESSED BY 0 Up to3Inc[ ��� 3jS �� �F LU l(1!JA ! TQOver 3 to 10 Incl _ FINL DATE/� //�� U) Contractor ❑ Over 10 to 50 Incl /q. `7� Z I am exempt under Sec Over 50 to 100 Incl l !! !!! VALIDATION FINAL -- - B&P C for Over 100 this reason BY Services,Swbd,MCC&Panelboards._ b Date 0-200 Amp Under 600 V Signature 201 -1000 Amp Under 600 V ❑_ `Over 1000 Amp or Over 600 V Exemption for Reg Maint Elect `y , L SINGLE FAMILY Temp Power Pole&Appurtenances T' HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ,?__ for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits �' -° Code) + r— C ❑ I,as owner of the property,will do the work and the structure Mlsc Conduits&Conductors _ rte i ri is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) • - and Professions Code) ® ==fir• _tM=1 CONSTRUCTION LENDING AGENCY _ _ _ -j'�I/.ti y(;_! I hereby affirm that there is a construction lending agency for the performance of of the work for which this permit Is issued (Sec 3097, PERMIT-FEE (Sub-Total) Civ C) _ PLAN CHECKING FEE 'a=�`'=—f )I;, Lender's Name !,S i PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the above TOTAL FEE Information Is correct 1 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 oroaarty for inspection urpos s SEE REVERSE FOR EXPLANATORY LANGUAGE SI E OF APPLICA AGE A E