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HomeMy Public PortalAbout10213 LOWER AZUSA RD_Electrical__ WORKERS' COMPENSATION DECLARATION 76A669ePwaie7 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self cE sobs insure, or a certificate of Workers- Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Labs C.))�q (' Policy Now 4114�� Company 'rP11,MA � r FOR APPLICANT TO FILL IN JOB a' @Y Z�SA Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS LOCALITY �Certified copy is filed with the county building ins 1 &2-Family, Sq. Ft. $ — $ i on department. Multi-family Sq. Ft. — NEAREST i s l CROSS ST. I y Date 6 Applicant Residential Swimming Pools OWNER OR pP FIRM NAME HQm t CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Recght $w. G MAIL t / �p COMPENSATION INSURANCE First 20 ie10 O /Q 0 ADDRESS "�2 (This section need not be completed if the work involved by ( i' C CITY the permit is for one hundred dollars ($100)or less.) Total No. .L,Additional / `/ I certify that in the performance of the work for which this PLAN CHECKAPPLICANT permit 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 d / 0 CITY Tel. No.ADDRESS 150 Additional ona � � /•li 0 Total No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT i � Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION VA C_ Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS ��� Ley with comply with such provisions or this permit shall be Top — FAU W.H. — deemed revoked. Hood — Fan 7—Other �-- CITY �, 0�''{� Tel. No. LICENSED CONTRACTORS DECLARATION �� �aJ 'Oa LICENSE OR Disp. — Room Air Cond. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 6 7417- Class. _ a (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROC SSED BY >_ and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR ,® Gam% Q License Number 60 Lic. Class C'-e 0 Up to 1 Incl. FINAL U S Sa{)� ��� L 01WOver 1 to 10 Incl. DATE Q� L/ VALIDATION 0 Contractor �)f"�- Date f ❑ Over 10 to 50 Incl. FINAL � I am exempt under Sec. Over 50 to 100 Inc. BY U LLl B.&P.C. for this reason Over 100 Services, MCC& Panelboards /p Bd , _ Date: 0-200 Amp.Amp. Under 600 V w... ttff � Signature 201 - 1000 Amp. Under 600 V _qtT 0 O Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole &Appurtenances ` �9�D HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License j Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits _ Professions Code): Misc. Conduits&Conductors5'"w:- I, as owner of the property, will do the work and the s• --_s•- structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Poo. . qL . _ 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name _?! 111-01130i PERMIT ISSUING FEE Lender's Address RLt i t' FEE 1 certify that I have read this application and state that the TOTAL YO 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 ove-mentio rty for inspection purposes. G �. `� SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure of Permittee Date ©$ WORKERS' COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O Thereby affirm that I have a certificate of consent to self CE-806G iarsure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No.0 //-�,rL'1yCompony r red FOR APPLICANT TO FILL IN JOB ❑Certified opy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS �!) El Certified Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ ,- tion department. Multi-family Sq. Ft. NEAREST CROSS ST. e Gesidential Swimming Pools OWNER OR �f Date Applicant FIRM NAME •�0,V)140"04 RTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec -r !O MAIL f LightL_Sw._ COMPENSATION INSURANCE First 20 /� Q ADDRESS (This section need not be completed if the work involved by Total No. Additional (7 Lj0 CITY -r� Tel. No. Z the permit is For one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit 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 —ZA A22 Total No.�_ CITY Tel. No. Date Applicant PERM NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP IT APPLICATION 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 /6lZ C n with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. CITY Tel. No / LICENSED CONTRACTORS DECLARATION Hood Fan —Other— LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. — REG. NUMBER Clas . (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P SED BY >_ and Professions Code,and my license is in full force and effect, t1 Size &Type HP, KW, KVA, or KVAR �0 �., Q License Number D Lic. Class4:;z t2 Up to 1 Incl. FINAL U Contractor &� ��(� Date Over 1 to 10 Incl. DATE ] _ ' VALIDATION 0 ❑ Over 10 to 50 Incl. FINAL l I am exempt under Sec. Over 50 to 100 Inc. BY `�/ C Over 100 © W B.&P.C. for this reason d Z Services, Swbd., MCC & Panelboards Z Date: 0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits •; a Professions Code): i.: •! � ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— , _ ! Business and Professions Code). 100. s�;= L =�� a _ CONSTRUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency for _:jaw'•.; _ a=1". the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). ("HH'•E'?�' [_i PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address 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 HI' °' 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 G ©s Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O : I hereby affirm that I have a certificate of consent to self CE 806E insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a.cer)ified copy thereof (Sec. 3800, Lab. C.) Poll* y No. TQ Company FOR APPLICANT TO FILL IN JOB 1 �y 41�Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 4!J Certified copy is filed with tht jWly building ins _ 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY alSAM 17- call tion department. -!!�i>A {It ( 'Yr� Multi-family Sq. Ft. NEAREST 6 CROSS ST. t , Date Applican<o daa� Residential Swimming Pools OWNER OR a FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw._ MAIL COMPENSATION INSURANCE g ADDRESS W • ' First 20 (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK _�r• I certify that in the performance of the work for which this APPLICANT permit 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 NOTICE TO APPLICANT: if, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT APPLICATION � � 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 with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG, NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR ESSED BY and Professions Code,and my license is in full force and effect. A t1 _ /` ry Size &Type HP, KW, KVA, or KVAR �[! Q License Number 1�b� Lic. Class Up to 1 Incl. FINAL Q t cor 1L GL' Date 3 1A Over 1 to 10 Incl. DATE / _ VALIDATION Contra F1 Over 10 to 50 incl. Q FINAL (0 I am exempt under Sec. Over 50 to 100 Inc. gY U W B.&P.C. for This Over 100 1 re o � Services, Swbd., MCC& Panelboards ® Z Pa 0- 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V El Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole &Appurtenances V HOME OWNER-BUILDER DECLARATION Z. I he/ebaffirm that I am exempt from the Contractor's License Sign with One Branc ircuit p Additional Sign Branch Circuits Lawthe following reason (Section 7031.5, Business and gProns Code): Misc. Conduits&Conductors I, as owner of the property, will do the work and the ;.1(= structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ ® -- Business and Professions Code). I,? i-1L .�,.� 000_� CONSTRUCTION LENDING AGENCY 3 ` ` ,. IN i I hereby affirm that there is a construction lending agency for _ the performance of the work for which this permit is issued PERMIT FEE (Sub-Total `0 I -IA IG ) E =?Il= (Sec. 3097, Civ. C.). ��// � PLAN CHECKING FEE Lender's Name �6—4- PERMIT ISSUING FEE Lender's Address L FEE Q 6010_. 11 A 11 A)'� TOTAL t S" I certify that I have read this application and state that the c�af above information is correct. I agree to comply with all County Ord'nan es and State laws regulating Electrical wiring, and hereb tho presentatives of this County to enter upon the ov entio d pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE e Signature of Permittee Date ©s WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that 6have a certificate of consent to self insure, or acQrtific"ate,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 ADDRESS �/ `�p ,r ❑ JOB l Certified copy is hereby furnishedResidential Bldgs.&Pools NO. EACH FEE ❑ . New gs. _ $ $ LOCALITY !c ( 1Pf Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP PAGE D/ PP+ARCEt� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.A Light L Sw. ,{ O-NFIRM NAME AJC COMPENSATION INSURANCE First 20 �✓ MAIL _ ( (This section need not be completed if the work involved by theADDRESS 1 �l. o/✓ lit' 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 4L 4V/-;,6 R 4 Tel.No.(R/Y 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 O APPLICANT Total No._Z Additional �' ADDRESS Date Applicant tl NOTICE TO APPLICANT: If, aft e aking this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. 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 e' p p y Power Apparatus&Large Appliances APPLICANT y ry y� w provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESSS G �` I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. `v J. r (commencing with Section 7000) of Division 3 of the Business and CITY - Tel.No � 7 Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR Over 50 to 100 Incl. REG.NUMBER ,� Class. a- Over 100 DISTRICT NO. P SED BY O License Number Lic.Class gyyoC��®s () �q ,�p� �/!^� Services,Swbd.,MCC&Panelboards Contractor-O/L47y�' -e / IDate 0-399 Amp.Under 600 V DATE st F- ❑ 400-1000 Amp.Under 600 V ` t✓ VALIDATION V I am exempt under Sec. Over 1000 Amp.or Over 600 VFINAL B.&P.C.for this reason LLI BRANCH CIRCUIT FEES BY I) L• /r Date: / / �f 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 egint.Elect. 15A,20A,208V To 27 .Ma7V Lighting Br.Circuits SINGLE FAMILY Temp. Power Pole&Appurtenances _ HOME OWNER-BUILDER DECLARATION r;•`,(,s` o 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 Code): •i Misc.Conduits&Conductors Fes.1(E�:_.f� 3 _ I,as owner of the property, will do the work and the structure _ is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I f AL , 1 = 60 �� and Professions Code). :�_ :Y, to i CONSTRUCTION LENDING AGENCY _ 1 hereby affirm that there is a construction lending agency for the CAih-`GE =ti`s performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) r�^•. r PLAN CHECKING FEE 0'41 I(,;-f_i01 0 i Lender's Name _ _ j: nc,_, PERMIT ISSUING FEE 1p t_. 1?tJ!y•.t Lender's Address I 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 enter upon the above-mentioned property for inspPcti R purpose /, SEE REVERSE FOR EXPLANATORY LANGUAGE SIG 01URE OF PERMITTEE DATE