The URL can be used to link to this page

Home My Public Portal About9592 LOWER AZUSA RD_Electrical__ WORKERS COMPENSATION DECLARATION 764306 10,81 APPLICATION FOR ELECTRICAL PERMIT I hgreby.affvm that I have a certificate of consent to self CE 8066 J �iOuke ori certificate of WArkers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY o`r'b certifihd copy$hereof(pec 3800 Lab C ) Policy No Company SA 0 FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS 47S Z ZvZ A Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ _ $ LOCALITY rr1e C44 ISI- ( -L. NEAREtion department Multi family Sq Ft CROSS ST T e r+. le 6/�X187 -Zkc Residential Swimming Pools OWNER OR Date , Applicant / FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec__�__Light Sw_ MAIL COMPENSATION INSURANCEADDRESS ,S (This section need not be completed If the work Involved by First 20 Total No Additional CIN TC kr C,� Tel No the permit Is for one hundred dollars($100)6r less) I certify that in the performance of the work for which this PLAN CHECK APPLICANT A1Q2 SOn /ADn►NAC p1EV 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 n Tel No 711f 'r'cf6 Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If after making this Certificate of APPLICANT n1OAA)AC OPV 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 /v fl I L L.EM 1t with comply with such provisions or this permit shall be Top _ FAU —W H — deemed revokedCITY ANA 1-t�( Tel No? /j�6�6 Z Hood _ Fan _Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby offirm 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 P SED BYE d and Professions Code and my license is in full force and effect p Size &Type HP KW KVA or KVAR �p O License Number ��'/0 Lic Class a Up to 1 Incl FINAL ,�s� V _ Over 1 to 10 Incl DATE ��—f VALIDATION a Contractor_CW-Am t CoMt Date 2f B Over 10 to 50 Incl v ❑ FI I am exempt under Sec Over 50 to 100 Inc B W IL 8&P C for this reason Over 100 Z Date Services Swbd MCC&Ponelboards 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 Temp Power Pole &Appurtenances HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits Law for the following reason (Section 7031 5 Business and Professions Code) ❑ Misc Conduits&Conductors I as owner of the property will do the work and the structure is not intended or offered for sale (Section Other(See Complete Free Schedule)_ 7044 Business and Professions Code) I , 2 7 3 317 A CONSTRUCTION LENDING AGENCY # • • • • • 2 1 hereby of4irm that there is a construction lending agency for the performance ofithe work for which this permit is issued PERMIT FEE - (Sub Total) • • l 5 0 0 (Sec 3097 Civ C ) /� PLAN CHECKING FEE • • • l 5005 NIA Lender s Name / �� PERMIT ISSUING FEE D 062687 Lenders Address I certify that I have read this application and state that the I TOTAL FEE /Sab above information is correct 1 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 y ✓F'at_ ` W,"t- 6�Z�� Signature of Permittee Date WORKER S COMPENSATION DECLARATION DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT 76A663 I hereby affirm that I have a certificate of consent to self insure 76A663 or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 3800 Lab C) 10 Policy No Company FOR APPLICANT TO FILL IN 'OB ADDRESS Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE ❑ 1 &2 Family Sq Ft _ $ $ LOCALITY Certified copy is filed with the county building inspection NEAREST department Multifamily Sq Ft CROSS ST Date•i Applicant o Residential Swimming Pools T ASSESSOR i MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec —Light FIRM RM N OR COMPENSATION INSURANCE RM NAME First 20 MAIL (Ttils section need not be completed If the workInvolved by the Total No Additional ADDRESS permit is for one hundred dollars($100)or less) I certify that in the performance of the work for which this permit CITY Tel No is issued I shall not employ any person in any manner so as to PIAN CHECK become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT Total No Additional ADDRESS Date P Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICf;+ O APPLICANT If after m ing 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 P MIT provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances PLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS r I hereby'affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl CITY Tel No (commencing with Section 7000) of Division 3 of the Business and � Professions Code and my license is in full force and effect Over 10 to 50 Incl LICENSE OR / 03�� a. Over 50 to 100 Incl REG NUMBER (� G Class O Ir A 9�7 �7 Over 100 DISTRICT NO P I SSED BY U License Number rJ 4A 7 7 7 Llc Class /J G l,��I r� f i Services Swbd MCC&Panelboards Contractor �VftA >r& CANS Date Z 9 0 399 Amp Under 600 V DATE O F1 - 400 1000 Amp Under 600 V 2—Z-7-4,1rVALIDATION W I am exempt under Sec Over 1000 Amp or Over 600 V FINAL d B&P C for this reasonBY fA BRANCH CIRCUIT FEES Date 15A or 20A 120V Lighting or Recept 44, Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits 2 y F141 Or More Branch Circuits Exemption for Reg Maint Elect 15A,20A 208V To 277V Lighting Br Circuits k C T e s SINGLE FAMILY Temp Power Pole&Appurtenances 330-6 -IJ6 60 HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractors License Law 1 ITEMS for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits Code) (i ITAL 36. 60 ❑ I as owner of theproperty will do the work and the structure Misc Conduits&Conductors is not intended oroffered for sale (Section 7044 Business Other(See Complete Fee Schedule) tHECV, 36 and Professions Code) ► CHANGE .011 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the ,�nrr��+, i � i rr: performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total) ii000-00101 � stir Civ C) PLAN CHECKING FEE 9025 1 PM12001t Lender s Name PERMIT ISSUING FEE Lender s Address I certify that 1 have read this application and under penalty of purjury state TOTAL FEE �p 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 inspectio oses SEE REVERSE FOR EXPLANATORY LANGUAGE SrIWIE TWIPERMITTEE DATE