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Home My Public Portal About5746 LOMA AVE_Electrical__ WORKER'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. Lab. C.) ' Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS 46, Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE. L S $ $ LOCALITY ❑.• Certified co Is filed with the count building inspection 1 &2-Family,Sq.Ft. PY Y 9 P NEAREST department. Multi-family Sq.Ft. CROSS ST. L_4,S Vcc j6 Date Applicant Residential Swimming Pools ASSESSoR MAP BOOK 7 1 PAGE P17 PARCEL O/ CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR Outlets:Rec.�Light_�Sw. FIRM NAME COMPENSATION INSURANCE First 20 0 �� (This section need not be completed if the work involved by the MAIL permit is for one hundred dolleis($100)or less.) Total No. Additional ADDRESS I certify that in the'performance of the work for which'this permit CITY. el 'T is issued, I shall not employ any person in any manner so as t0 PLAN CHECK GC/ become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 D APPLICANT Total No. Additional I oy 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 Ileieby 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 rel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSEClass. ' Over 50 t0 100 Incl. REG.NUMBB ER Q. Over 100 DISTRICT NO. PRO ED BY 0 License Number Lic.ClassA ,y V Services,Swbd.,MCC&Panelboards !/a cc Contractor Date 0 399 Amp. Under 600 V DATE j 0 ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V /F VALIDATION 0 V Over 1000 Amp.or Over 600 V FINAL LLI d B.&P.C.for this reason BRANCH CIRCUIT FEES BY co 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 FAMILY Temp.Power Pole&Appurtenances AC i°ir HOME OWNER-BUILDER DECLARATION "z7e�ttir 1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit _. ��+—O_ for the following reason (Section 7031.5, Business and Professions Additional Sign Branch CircuitsIt i; .,. Code): nduits& -fi El1,I,as owner of the property,will do the work and the structure Misc.CoI I-�t AL 109- 66 is not intended or offered for sale Section 7044, Business Other See Complete Fee Schedule -• .66 _ " q and Professions Code). CHANGEoil_ 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.) 0000-0001 1l 8/9, , PLAN CHECKING FEE 7516 1 Ar}-10:40 Lender's Name PERMIT ISSUING FEE Lender's Address 1 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, e(upon the above-mentioned property forr'nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /tr 1 b SIGNATURE OFPERlWTTEE F DA E 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 there/of(Sec. 3800 Lab.C.) [ JY Policy No/-!� Companyy�'&4- y FOR APPLICANT TO FILL IN JOB E ADDRESS J ❑ Certified copy is hereby furnisheder/ %/��N New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY A4,6T ET Certified copy is filed with the county building inspection i&2-Family,Sq.Ft _ NEAREST de artment. Multi-family Sq.Ft. CROSS ST. �✓ �l� Residential Swimming Pools _ ASSESSOR a ( h MAP BOOK PAGE PARCEL Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR ��n COMPENSATION INSURANCE Outlets:Rec.—Light Sw. FIRM NAMEMa /7 First 20 MAIL (This section need not,be completed.if the work,involved.by the ADDREss r� permit is for one hundred dollars($100)or less.) Total No. Additional I certify that in the performance of the work for which this permit CITY �PG Tel.No. is.issued, I shall not employ any person in any manner so as to I I PLAN CHECK become subject to the Workers'Compensation Laws. - Lighting Fixtures First 20 APPLICANT ' if 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 SUCK PERMIT APPLICANT % ' ,'Iv provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances (r LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS ?� /VW 00 I hereby•affirm that I am licensed under provisions of'Chapter 9 Over 3 to 10 Incl.. n�'/ (commencing with Section 7000) of Division 3 of the Business and- CITY lV�LTel.No. OgJ 5 Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. �v LICENSE OR Class. Over 50 t0 100 Incl. REG.NUMBER 3 G 7� a n? C- y� Over 100 DISTRICT NO. PROCESSED BY 0 License Number 6 7 Lic.Class .j r Services,Swbd.,MCC&Panelboards �.>/�G ��tsg��li� T_ Contractor—rf/"G/N ��C��%�/Dat '�y�'/ •%3 0-'399 Amp.Under 600 V FINAL O ❑ DATE I am exempt under Sec. 400-1000 Amp.Under 600 V Over 1000 Amp.or Over 600 V FINAL VALIDATION d B.&P.C.for this reason BRANCH CIRCUIT FEES BY Date: 15A,or 20A,120V,Lighting or Recept Z_ 1 To 10 Branch Circuits. Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuits Exemption for Reg.*Maint.Elect. 15A,20A,208V To 277V Lighting Sr.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances "'" p ...... s HOME OWNER-BUILDER DECLARATION ;ILC•S n T 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 -1Uf iii•. Code): .:. _...... ..._-................ .... ..� NEMS ❑ 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) TOTAL 9 iTAL 34® '� 3 and Professions Code). _ .. ................... ......... CHECK K CONSTRUCTION LENDING AGENCY ' I hereby affirm that there is a construction lending agency.for the CHA—11GE .0 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) -'"'— '....""""' Civ.C.) PLAN CHECKING FEE 01300-0001 1;`15 93 Lender's Name - PERMIT ISSUING FEE a�L 662I PM12:09 Lender's Address 'i/ _............................. .._ _..._.._.._ I certify that I have read this application and under penalty of purjury state TOTAL FEE 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 pf this Coun y to enter upon the above-mentioned property for inspection p rposes" SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PE DATE WORKERS'COMPENSATION DECLARATION CE 806G (Z-80) 'APPLICATION FOR LECTRICAL PERMIT I hereby affirm that I have a' certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or: a certified.copy thereof(Sec. 3800,Lab. C.) � FOR APPLICANT TO FILL IN ,JOB Policy No 2:kS71L Company'�0 rz Q P <� 1�L EACH NO. FEE -ADDRESS �^ �� . New Residential Bldgs.&Pools 0 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY Multi-family Sq. Ft. NEAREST Certified copy is filed with the county building inspection CROSS.,ST. ��; / 0department. Residential Swimming Pools OWNER OR FIRM NAME (i Date' "Applicant � �` Outlets: Re --Light Svv. AIL / First 20 ADDRESS �7c CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. } COMPENSATION INSURANCE o PLAN CHECK O. PPLICANT O (This section need not be completed if the work involved by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS r Additional O Total No. I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. permit is issued; I shall not employ any person in any manner PERMIT V so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT G / rr,�7 ' w Oven Dryer_W.M._ ADDRESS e, N Date Applicant Top FAU W.H.. CITY / �//7� tTel No. / Z Hood — Fan _Other_ J�ir/ C�c3b/'7�� b7� NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond._ LICENSE OR Exemption, you- should become subject to the Workers' REG.NUMBER 'Class b' Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. =2T Y with comply with such provisions or this permit shall be deemed revoked. ' Size&Type HP,KW,KVA,or KVAR Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE /r �Q/ VALIDA LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY- 9 Y-9 (co'mmencing with Sectiori 7000) of Division 3 of the Busi- Over 100 � ness and Professions.Code, and my license is in full force and effect. Services W License Number r � 5 Lic.Class 0-200 Amp.Under 600 V 201-1000 Amp. Under 600 V !/ Contractw610 Date /�� Over 1000 Amp.or Over 600'V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 2 4 0 1.2 A Additional Sign Branch Circuits License Law for,the following reason (Section 7031.5, Busi- #.0/01:0;0 e 2 ness and Professions Code): - Misc.Conduits&Conductors 2'0-1.2 5 0 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule);- structure chedule)=structure is not intended or offered for sale (Section .0.0 0 1 2 5 025 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY2,O 9'=8 1 1 hereby affirm that there is a construction lending agency' for the performance of'the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth.Permit Fee) Lender's Address PERMIT ISSUING FEE 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 .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 Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT CE-806G (2-801 I hereby affirm that I, have a certificate of consent to self COUNTY OF LOS ANGELES CI BUILDING AND SAFETY insure, or a certificate.of Workers'Compensation Insurance,'or a certified copy thereof(Sec. 3800,Lab'.C.) (yam( `/,�, ./,t r FOR APPLICANT TO FILL IN ,LOB �� Policy Nadi 16�� Compan}y.^�" u G ADDRESS New Residential Bldgs.&Pools EACH' NO. FEE d c- •.Certified copy is hereby furnished. 1.&2-Family,Sq. Ft.' $ — $ LOCALITY �.:•' C Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST ar ment• Residential Swimming.Pools OWNER OR FIRM NAME a/ DateApplicant.`-- �Z�� MAIL Outlets: Rec. Sw. Sd First 20 Q ADDRESS a5 c3 4p CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. } COMPENSATION INSURANCE PLAN CHECK 0- APPLICANT APPLICANT O (This section need not`be completed if the work involved . () U by the 'permit is for one,hundied dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS cc Additional I certif that in the Total No.� 0 y, performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. U permit is issued,.I•shall not employ any person in any manner PERMIT LU so as to become subject to the W s' Compensation Laws. Range_Heater_D.W. APPLICANT Q d Oven _ Dryer—W.M. ADDRESS ^ to l6 < �$7. pro �- z Date Applicant ^�' Top FAU _W.H.._ �?�� l . Hood Fan _Other_ CITY 7, G rye Tel No. teAl 12-c- OTICE TO,APPLICANT: If, after making this Certificate of Disp. Room.Air Cond LICENSE OR Exemption, you should become subject to 'the. Workers' REG. NUMBER3/ Class Compensation. piovisions'of•the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED BY' with, comply with such provisions or this permit. shall be Size&Type HP,KW, KVA;or KVAR �•� deemed revoked. Up to 1 Incl. FINAL Over 1 to Ove10 Incl. .._- LICENSED CONTRACTORS DECLARATION ��- VALi DATIONr l DATE 10 to 50 Inc I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 �• �' ness and Professions.Code, and my license is in full force and'. effect. ! Services 160119M License Number��-S j Lic.Class 0-200 Amp. Under 600 0 _eG . 201-1000 Amp. Under 600 V 0 Contracto4el) //QjZit�� Date IC �� Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm .that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): 2.4 4 0 6 A Misc.Conduits&Conductors 1,.-as owner of the'property, will do the work and the Other (See Complete Fee Schedule)— #-0 0 0 0 o'2 structure is ,not intended or offered for sale,,(Section 7044, Business and Professions Code).12 0 0.2 2 0 CONSTRUCTION LENDING AGENCY . -I hereby.affirm that there is a construction lending agency ;o o - 22 0 0 v for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,civ.C.). 0 3'1 :6—8 1 Lender's Name' PLAN CHECKING FEE (One-Fourth Permit Feel ` Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE �� 0 above information is correct. I agree to comply with all County ordinances anti State .laws regulating Electrical wiring, and hereby authorize representatives of this County.to enter upon the abo -me i/o�ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date