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HomeMy Public PortalAbout4958 LOMA AVE_Electrical__ WQRKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) ���L��ATD®� ®� EL��TRBCs�L P��6�i�� 76A663 I hereby affl.m.that I have a certificate,of consertit to self Insure;or a c®rtificate 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 r � ADDRESS G' W wA va Certified copy is hereby furnished New Residential Bldgs &Pools NOEA` FEE LOCALITY El1 Certified copy is fled with the county bud1 &2-Family,Sq Ft �a $ ding inspection _ NEAREST department Multi-family Sq Ft CROSS ST \( Residential Swimming Pools ASSESSOR /pp �j Date Applicant MAP BOOK O P PAGE 0ll PARCt'��/ CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec -Light Sw FFIIRM NAME 9 COMPENSATION INSURANCE Rist 20 MAIL (This section need not be completed the work involved by the Total No Additional ADDRESS/3 (J � permit Is for one hundred dollars($1000)or less) I certify that In the performance of the work for which this permit CITY Tel J_ 77� Is Issued, I shall not employ any person In any'manner so as to PLAN become subject to the Workers'Compensation Laws a Lighting Fixtures First 20 APPLICANT K 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 prov(sions of the Labor Code, you must forthwith comply with such PERMIT provisions or this permit shall be deemed revokedPower 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 Over 50 to 100 Incl LICENSE Class REG NUMBER a Over 100 DISTRICT NO PROCESSED BY - Q License Number Llc Class pV Services,Swbd,MCC&Panelboards �d p �+f Contractor Date 0-399 Amp Under 600 V FINAL DATE 400-1000 Amp Under 600 V ~ ❑ I am exempt under Sec 3 VALIDATION V Over 1000 Amp or Over 600 V FINAL W B&P C for this reasonBRANCH CIRCUIT FEES BY d W. 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 SINGLE FAMILYMtn{ jas Temp Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION - — I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 330.3 for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits Ci � )�t+ ode) 1 LJ I, as owner of the property,will do the work and the structure Mlsc Conduits&Conductors TOTAL 275--B = 0=� Is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) CV1D Er_,; ' and Professions Code) `t 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) s17 Civ C) _.4 U{I—�I:1,1 1 };`•` PLAN CHECKING FEE 4'1if-,',+ Lender's Name PERMIT ISSUING FEE Lender's Address /h I certify that I have read this application and under penalty of purfury 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�rr�spe ,Ion Pur ses SEE REVERSE FOR EXPLANATORY LANGUAGE I! i a ATURE 01 PERMITTEE DAIE WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) . . �J I hereby affirm that I have a certificate of consent to self insure, 76A663 APPUCATION FOR ELECTRBCAL-PERM 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) .*N Policy No Company FOR APPLICANT TO FILL IN JOB - ADDRESS ❑- Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE ❑ LOCALITY _ $ $ Certified copy is filed with the county building Inspection 1'&2-Family,Sq Ft NEAREST department Multi-family Sq Ft CROSS ST Q. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec -Light Sw OWNER OR COMPENSATION INSURANCE FIRM NAME (This section need not be completed the work Involved by the First 20 MAIL Total No Additional ADDRESS ,4m: permit Is for one hundred dollars x($1000)or less.) - I certify that In the performance of the work for which this permit CITY N t 00 el No Is Issued, I shall not employ any person In any manner so as to PLAN CHECK l0 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 LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 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 CITYhDf f I No Professions Code,and my license Is In full force and effect Over 10 to 50 Incl Over 50 to 100 Ind REG NNU BER Class SE OR d Over 100 - DISTRICT NO PROCESSED BY 0 License Number LIc Class y V Services,Swbd,MCC&Panelboards �O Q Contractor Date 0-399 Amp Under 600 V FINAL DATE �j O ❑ I am exempt under Sec 400-1000 Amp Under 600 V �2� LU Over 1000 Am or Over 600 V VALIDATION P FINAL CL B&P C for this reason BRANCH CIRCUIT FEES BY (1) Date 15A or 20A,120V,Lighting or Recept 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 SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 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 Code) © 1,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) and Professions Code) CONSTRUCTION LENDING AGENCY 1 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 7 PERMIT ISSUING FEE Lender's Address TOTAL FEE I certify that I have read this application and under penalty of purjury state 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 a Ion p r ,oses --) (,1 c�/ SEE REVERSE FOR EXPLANATORY LANGUAGE {L, l Z l®• {l� WA_rLT7F PEPIOTTEE DATE