The URL can be used to link to this page

Home My Public Portal About9925 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION C -663 10181 APPLICATION FOR ELECTRICAL, PERMIT I 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:!`�Breof r 3800,L-a--b.C.) 1� li pmpanIq�"�U l+IO� / i F FOR APPLICANT TO FILL IN f JOB Po ADDRESS 9gas AOWUZ A. ped ❑ Cgrtified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ❑ 1 & 2 Family,Sq.Ft. $ — $ LOCALfFY Certified copy is filed with the county building .inspection lumetle de rtment. Multi-family Sq.Ft. CROSS ST. NEAREST 2 Residential Swimming Pools OWN R Ohl Date Applid4r�1!�/"v � /�6•"p� FlRM NAM �: H1l► c, i� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light Sw. MAIL COMPENSATION INSURANCE ADDRESS`F Dy _F J G1jAI (This section need not be completed If the work Involved by the First 20 CITYsg�01- �` Te .�� permit.is for one hundred dollars($100)or less'.) Total No. Additional LAN I certify that In the performance of the work for which this permit APPLICANT K is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compgnsation Laws, Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT T F Exemption,you should become subject to the Workers'Compensation Range— Heater_ D.W. APPLICAN provisions of the Labor Code, you.must forthwith comply.with such Oven _ Dryer _ W.M._ ADDRESS LJ&- Qw provisions or this permit shall be deemed revoked. Top . FAU W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY �1 �� Te 3, I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR esc� L Disp. — Room Air Coad. REG.NUMBER �ov ,. C �u (commencing with Section 7000)of Division 3 of the Business and Z yj Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRI� O PR ED BY Size&Type HP,KW,KVA,or KVAR O License Number` 9"S,)Lj9 Lic.Class Up,to 1 Incl. FINAL Q Cont /J�16�8�►►Date 9 V Over 1 to 10 Incl DATE VALIDATION Q ❑ Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY �Lq_JA BAP.C.for this reason Over 100 Z Date: Services,Swbd.,MCC& Panelboards , 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 FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ��Z I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits _,_�,n� 33 �� Code): ww.77�t►► ❑ . I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 ITEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ ► TOTAL 33.00 and Professions Code). �A ■�I CONSTRUCTION LENDING AGENCY CASH I hereby affirm that there is a construction lending agency for the CHANE .00 'performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE 0000-0001 3/22/91( Lender's Name PERMIT ISSUING FEE 9632 1 Mf110;,(6 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _)M C a o Signature of Permittate WORKERS'COMPENSATION DECLARATION 76-663 tD/B, APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, CE-Bose 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."ffi-EZ Company 11�11� FOR APPLICANT TO FILL IN JOBf w Certified copy is hereby furnished. New Residential Bldgs.&Po1�o.l��s'� 2� EACH NO. •FEE ADDRESS Z WkKY S Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft.-L: - $ — $ LOCALITY Ci t department. 11 Multi-family Sq.Ft. NEAREST Residential Swimming Pools CROSS ST Date Applicant OWNER OR FIRM NAME 1+ CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light _ Sw. — MAIL COMPENSATION INSURANCE ADDRESS Q (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 CITY < Tel.No. Z I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person in any manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional 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 r provisions or this permit shall be deemed revoked. Top — FAU _ W.H. LICENSED CONTRACTORS DECLARATIONCITY S O�T Tel.No. Hood — Fan Other_ -01 I hereby,affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR _Aall (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER - � Class. C— Professions Code,and my license is in full force and effect. DIST>tICT PROC ED BY Power Apparatus 8 Large Appliances ySize&Type HP,KW,KVA,or KVAR License Number �� Lic.Class Up to 1 Incl. FINAL ContractorDate / ' !/ Over 1 to 10 Incl. DATE6 �( VALIDATION e � � Over 10 to 50 Incl. FINAL. ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C.for-this reason Over 100 •III. Services,Swbd.,MCC&Panelboards N Date: 0-200 Amp.Under 600 V P Signature 201 - 1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole& Appurtenances + T.* HOME OWNER-BUILDER DECLARATION. Sign with One Branch Circuit tf,vRC.�C I hereby affirm that I am exempt from the Contractor's License Law c for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 3307 124.1). Code): 1 ITEMS ❑ I,as owner of the property, Misc.Conduits&Conductors pe ty,will do the work and the structure Complete See is not intended or offered for sale (Section 7044, Business Other( p ete Fee Schedule) TOTAL 124. 15 and Professions Code). CKCK 124.15 CONSTRUCTION LENDING AGENCY `WGE .011 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) PLAN CHECKING Civ.C.). FEE 0000—Ml 8/13/90 Lender's Name ` 0 2365 1 A110%47 PERMIT ISSUING FEE Lender's Address 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 property for inspection purposes. q� � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ofPeermdtee Date