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Home My Public Portal About9220 LONGDEN AVE_Electrical__ *ORKER'S COMPENSATION DECLARATION60.89 DPW glee APPLICATION FOR ELECTRICAL PERMIT I hereby affitm that I have a certificate of consent.to self Insure, or 8 certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.. copy thereof(Sec.380.0 Lab.C.) c`� d Ppli No. W Company v v�t� FOR APPLICANT TO FILL IN JOB yy / ADDRESS ZiG/ Certified copy Is hereby furnisheddw New Residential Bldgs.&Pools EACH NO. FEE LOCALITY ❑ Certifie copy's filed with the cilding coon 1&2-Family,.Sq..Ft. f? $ _ $ depa.. ent. `� Multi-family.Sq.Ft. CROSS ST. (//(/J Date " Applicant Residential Swimming-Pools ASBEgSOR / MAP BOOK PAGE 13/ PARCELdQ��^ ERTIFICATE OF EXEM�ION F.OM ORKERS' y � OWNER OR COMPENSATION IN R E Outlets:Rec._Light Sw. FIRM NAME �('.� Jay/ First 20 'f 0 (This section need not be completed if the work Involved by the Total'No.�_ Additional ADDRESS ` y permit is for one hundred dollars($100)or less.] I I certify that in the performance:of the work for which this permit CITY T,Gr Tel.No. 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 PLAN CHECK . r1� j p �. APPLICANT 6v Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS. NOTICE TO APPLICANT: If, after making this Certificate of 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 W ,� AJ APPLICANT provisions or this permit shall be deemed revoked. 41 OR MORE:BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS. d 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 and CITY �yyg,9 Tel. ox" ,;_&W ala V Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE oR IIX Power Apparatus&Large Appliances REG.NUMBER Claes L-icenss'Number �� 1" Lie.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. p PRC ED BY I-- Up to 3 Incl. �i�p W Contractor Date Over 3 t 10 Incl. DAT Over 10 to 50 Incl. z ❑• I am exempt under Sec. Over 50 to 100 Incl. ? ` VALIDATION B.&P.C.for this reason Over 100 FINAL S �s rCPOCelb Date: Signature -1000 Amp.Under 600 V Over 1000 Amp.or Over 600 V ❑ Exemption for Reg.Maint.Elect. SINGLE FAMILY - T.emp,.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I.am;exempt from the Contractor's License Law t {j=e :•:,C ; for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits - Code): w, ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors ,.. r i - -�;,�• Is not intended or offered for sale.(Sectlon 7044, Business Other(See Complete Fee Schedule) and Professions Code). CONSTRUCTION LENDING AGENCY Coff 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 Civ.C.) _, r,;•jT, W; {r,0r,x PLAN.CHECKING FEE -w - Lender's Namef.,sx PERMIT ISSUING FEE 76 Lender's Address TOTAL.FEE I certify at.I have read this application and state that the above . Inform on Is cec,(f I agree to comply with all County ordinances and to lawsre lating Electrical wiring, and hereb authorize re antatives his County to enter upon the abo a-m ntioned P e: for in a tion purposes, SEE.REVERSE FOR EXPLANATORY.LANGUAGE GNATURE QF PLICANT OR AGENT DATE - WORKERS'COMPENSATION DECLARATION 10i81 APPLICATION FOR ELECTRICAL PERMIT . I herebyy CE-806 affirm that I have a certificate of consent to self CE-806G .insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES ` . BUILDING AND SAFETY orat gy+lfie�4opx jhe JP_(Sec. 3800, Lab. Policy a.e /(� �Company FOR APPLICANT TO FILL IN JOB EACH ADDRESS Certified copy is hereby furnished. New Residential Bldgs. &Pools NO. FEE LOCALITY--;. r,. Certified copy is filed with the county building i 1 &2-Family, Sq. Ft. $ _ $ � tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Residential Swimming Pools Date ��' Applicant OWNER OR � ' FIRM NAME F CERTIFICATE OF EXEMPTION FROMWORKERS' � sMAIL Outlets: Rec Li ht Sw. COMPENSATION INSURANCE ! g f ADDRESS This section need not be completed if the work Involved b First 20 ( P Y CITY Tel. No n the permit Is for one hundred dollars($100)or less.) Total No. Additional .� roC I'certify that in'the performance of the work for which this. pPPLICANTK permit is.issued,I shall not employ any person in any manner so as to become subject to the Workere-Compensation Laws. Lighting:Fixtures First'20 7 ADDRESS l' 1 Additional Total No. CITY" Tel. No. Date Applicant Fixed Appliances Not Over 1 HP' PERMIT NOTICE TO APPLICANT: if, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code; you must forth- Oven _Dryer _W.M.— ADDRESS RA k AA with. comply with such. provisions or this permit shall be Top' — FAU —W.H. — deemed revoked. CITY Tel. Na�l1Zf" LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other— Disp. _ Room Air Cond. LCEClass. I`hereby affirm that I am licensed under provisions of Chapter 9 REG.REG. (commencing with-Section 7000)of Division 3.of the Business DISTRICT NO. PROC SED BY and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances — r Size&Type HP, KW, KVA, or KVAR' E 0 0 License Number313�a� Ljc..Class. INAL / W ( Up to 1 Inc[.IlDATE �/ Ili c.�CooJ.•cwt S-'�-P Over 1 to 10 Incl. VALIDATION Contractor Date. I Over 10 to 50 Incl. t= ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason . Over 100 44 Services,Swbd..,MCC&Panelboards `� 7�y Z 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. SINGLE FAMILY1 0 Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ` o 0 0 o c2 I hereby affirm that I am exempt from the Contractor's License Law for the following reason.(Section 7031.5, Business and Additional Sign Branch Circuits _ C� Professions Code): ❑ I, as owner of the property, will do the work and the Misc..Conduits&Conductors o,: 1 4 structure.is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ► 7044, Business and Professions Code). 1 C 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 .PERMITFEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's NameO Lender's:AddressIT ISSUING FEE . PERM 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 i ordinances and State laws regulating'Electrical wiring, and herebauthorize represent ive f this County to enter upon I the.7ove-mentioned op rty o inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of rmittee Date I