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Home My Public Portal About8848 LONGDEN AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 76A663 u 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 thereof.(Sec. 3800 Lab..C.) Policy No. Company "' FOR APPLICANT TO FILL IN JOADDB RESS ❑ Certified copy is hereby_furhished. 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. sP P Date ` Applicant Residential Swimming Pools ASSESSOR // MAP BOOK ell 1 PAGE OO� PARCEL e10 CERTIFICATE OF EXEMPTION FROM WORKERS' 1/ E wNE R + COMPENSATION INSURANCE Outlets:Rec. Light Sw.i�— � AMQ S First 20 ff/r� 90 e3 (This section.need not be completed if the work involved by the 0 MAIL ADDRESS H PH per is foforone hundred dollars($100)or less.) Total No. _ Additional I certify that in'the performaince`of the work for which this permit CITY Tel.No. is issued, I shall not employ any person in any manner s0 as t0 PLAN CHECK become,subject to the Workers'Compensation Laws. Lighting Fixtures 15, First 20 APPLICANT Total No. Additional. ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE,T.O 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 AppliancesAPPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby'affl�m that I'am licensed under provisions sof 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. LICENSE Class. a Over 50 to 100 Incl. REG.NUMBER Over 100 DISTRICT NO. - P O ESSED BY O License Number Lia Class r, V Services,Swbd.,MCC&Panelboards Contractor Date 0-399 Amp.Under 600 V FINAL O ❑ 400-1000 Amp.Under 600 V DATE I am exempt under Sec. VALIDATION V Over 1000 Amp.or Over 600 V FINAL UJ B.&P.C.for this reason BRANCH CIRCUIT FEES By CIL 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 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 1•`==17(� so 1 I Code): 1. TEN, ........ ._... Iry Conduits&Conductors L I,as owner of the property, will do the work and the structure Misc. - - •�s• c s is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) b=1 I AL �` 1 and Professions Code). D . " zCHECK` _90; CONSTRUCTION LENDING AGENCY t+ - Wi.YID I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued Sec. 3097, '"^`– ^ p P ( PERMIT FEE (Sub-Total) � (:�1=ilysas". Civ.C.) PLAN CHECKING FEE Lender's Name �/ 010[I.'•l-0 3'.J 1 7/._ - Z PERMIT ISSUING FEE Y= .. -. .....c. :s�-e-: Lender's Address 0979 f ''It i�1 ;r ,:7 kcertify that I have read this application and under penalty of purjury state TOTAL FEE x 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 inspe tion purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE SI ATURE OF PERMI EE - DATE WORKER'S COMPENSATION DECLARATION 76A663 9 DPW(t2-91) APPI j CACI N TO.R EL�ECTMAL� �""ERN u 0 �J I hereby affirm that I have a certificate of consent to self insure, 76A66 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.) Policy No. Company FOR APPLICANT TO FILL IN JOBEl i �O,r/ ADDRESS w!7 Certified copy is hereby furnished: New Residential Bldgs.&Pools NO. EACH FEE d� — $ $ LOCALITY / G/T Certified co is filed with the count building inspection 1 ?-Family,Sq.Ft. 9 O PY Y 9 P NEAREST / I/ department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR ° ' COMPENSATION INSURANCE Outlets:Rea—Light Sw• FIRM NAME RA1,(/s //t� First.20 MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS permit is for'one hundred dollars($100)or-less:)' I certify that-in'th'e performance of the work for which this permit CITY G�T Tel.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK 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 APPLICANTL,a�jL P� 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. } LICENSEClass. a ' Over 50 t0 100 Incl. REG.NUMBB ER Over 100 DISTRICT NO. P90gfPSED BY O License Number Lic.Class Q Services,SwbdFINAL �CC Pay�lb4 rs d� Contractor Date, 0- 9 mp.Under 600 V � DATE O El 400-1000 Amp.Under 600 V � VALIDATION U I am exempt under Sea Over 1000 Am or Over 600 V W P• FINAL d -B.&P.C.for this reason - BRANCH CIRCUIT FEES BY Date: 15A,oc20A,120V,Lighting or Recept. f Z 1 To 10 Branch Circuits Signature 11To 40 Branch Circuits El Exemption Or More Branch Circuits . Exemption for Reg:Maint:'Elect. 2 .15A,20A,208V To 277V Lighting Br.Circuits '- SINGLE FAMILY Temp.Power Pole&Appurtenances HOMEOWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ;. 1:1W7 for the following reason (Section'7031.5, Business and Professions Additional Sign Branch Circuits �rt {Code): 1 ITEMS 4y __..................-,..,.. ..,. I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 61 . 65 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _.._......,._. .. tt!! and Professions Code). CHECK 61.65 CONSTRUCTION LENDING AGENCY CHANGE .00 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) 1p Civ.C.) 0000-0001 3 1197 PLAN CHECKING FEE i Lender's Name PERMIT ISSUING FEE y 1 AM i 10 a�,I o7� _ .. C'�r1'` � Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE (p !v 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 insp tion purposes. c� SEE REVERSE FOR EXPLANATORY LANGUAGE SI ATURE OF PERMITTEE ,DATE