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Home My Public Portal About5753 LOMA AVE_Electrical__ Wm that I 'COMPENSATION DECLARATION 76-806 10/81 APPLICATION FOR ELECTRICAL PERMIT � hereby affirm that I have a certificate of consent to self insure, CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB C ❑ Certified co is hereby furnished. EACH NO. FEE ADDRESS copy Y New Residential Bldgs.& Pools $FtLOCALITY S il Famy, q. . — $ Certified copy is filed with the county building inspection 1 & 2- — department. Multi-family Sq.Ft. NEAREST CROSS ST. Date -5 5F Applicant Residential Swimming Pools OWNER OR Cy FIRM NAME /9 t✓/ CERTIFICATE OF EXEMPTION FROM WORKERS'. RLight Sw� AIL Outlets: ec COMPENSATION INSURANCE �� ADDRESS .� yy/ �= (This section need not be completed if the work involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Additional PLAN CITY Tel.No. 1 certify that in the performance of the work for which this permit APPLICANT CHECK is issued, I shall not employ any person in any manner so as to 7 become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 C ADDRESS Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances 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_ D.W. APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS O d e provisions or this permit shall be deemed revoked. Top — FAU _ W.H. CITY Tel.No. Hood _ Fan _ Other LICENSED GONTRACTORS DECLARATION f ' _ I hereby affirm that I am licensed under provisions of Chapter 9Disp. — Room Air Cond. LICENSE OR l (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER 31-�7 1/ Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSED Size& Type HP,KW,KVA,or KVAR Q License Number J / Lic.Class Up to 1 Incl. FINAL U �. Over 1 to 10 Incl. DATE 7 pC Contractor w Date L o 27 VALID ON Over 10 to 50 Incl. FIN U ❑ I am exem t under Sec. Over 50 to 100 Inc. g J /, Ill Over 100 0" B.&P.C.for this reason � N Services,Swbd.,MCC& Panelboards Z ate: 0- 200 Amp.Under 600 V Signature - 201 - 1000 Amp.Under 600 V 9 7 2 1 A ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V # 0 0 0 0 0 SINGLE FAMILY Temp.Power Pole& Appurtenances - 21L75 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law o - o 2 4,7 55 for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code): El 1, Conduits&Conductors o 4'3 1 °8 8 I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) is not intended or offered for sale (Section 7044, Business ► and Professions Code). 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.). PLAN CHECKING FEE Lender's Name � PERMIT ISSUING FEE Lender's Address Q 4 ,251 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 representatives of this County to enter upon the above-mentioned prop/e'rtt for in pectti purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee VDate �>rm that I ' COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT --o-ria-" ew(firm that have a certificate of consent to self insure, CE-806G certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) '3l�G b Sf4�e 4f, Policy No.l7 S Company FOR APPLICANT TO FILL IN JOB ADDRESS 57S y n A ❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ✓ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY 7 department. Multi-family Sq.Ft. NEAREST �/ /� CROSS ST. �f f's 1,� f' Date11-1115'a Applicant �f"' ��Q��Y•�' C 01� Residential Swimming Pools OWNER OR FIRM NAME /'h ar,� C, C�Ci�••/-f Gi/ CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec V Light -2-- Sw. "MAIL p COMPENSATION INSURANCE ADDRESS First 20 (This section need not be completed if the work involved by the CITY s'�e tom."7Z� Tel.No.��S"� permit is for one hundred dollars($100)or less.) Total No. Additional I certifythat in the performance of the work for which this permit PLAN CHEC P APPLICANT 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 Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances 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_ D.W. _ APPLICANT �� provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS ifi � .r, provisions or this permit shall be deemed revoked. To r^ P P — FAU _ W.H. n Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY�.o ��, I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OFr (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER S 5v Class. 0(� Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NOh. PROCESSED BY Y- - � Size& Type HP,KW,KVA,or KVAR ✓ 1 O License Number! �3 �!% Lic.Class ~ Up to 1 Incl. FINAL U ContractordJ��oCrX.'�` � �� 7� Over 1 to 10 Incl. DATE c� O Date �� VALIDAPION 1 ❑ Over 10 to 50 Incl. FINA f" I am exempt under Sec. Over 50 to 100 Inc. BY IIII U Over 100 0. B.&P.C.for this reason N Services,Swbd.,MCC& PanelboardsC� /l Z Date: 0- 200 Amp.Under 600 V S v Signature 201 - 1000 Amp. Under 600 V 8 7 7.3 A ❑ Over 1000 Amp.or Over 600 V # ° 0 0 0 0 2 Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole& Appurtenances ° - 33.75 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit = I hereby affirm that I am exempt from the Contractor's License Law o 0 0 33 7 5 6 for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 0 1. 1 4 e 8 8 ❑ 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) and Professions Code). 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) 3 ti Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE f Lender's Address I certify that I have read this application and state that the above TOTAL FEE `3,? 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 inspectio u poses. �j:5--r SEE REVERSE FOR EXPLANATORY LANGUAGE Stgnatur P itt a Date