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Home My Public Portal About5232 MCCLINTOCK AVE_Electrical__ WORt{ERS'COMPENSATIONDECLARATION CE-806G (2.80)- APPLICATION FOR ELECTRICAL. PERMIT I hereby affirm,that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certificate of Workers'CompensatioU Insurance,or ' a certified copy thereof(Sec.3800,Lab.C.) �} FOR APPLICANT TO FILL IN 7� Policy NdCompanyLD�1l��J1�Lr .ADDRESS C d ./ G New Residential Bldgs.&Pools EACH NO. FEE. ❑ Certified copy is hereby furnished.. 1 &2-Famil.y,Sq.Ft. $ — $ LOCALITY J., ❑�tified co is filed with the count building p Multi-family Sq. Ft. NEAREST _ y copy y gins action CROSS ST department. Residential Swimming Pools OWNER OR f �,,,11 �./y/A ` /I y j� FIRM NAME .c— Date V3 VApplicant {sE Outlets: Rec.&ight� Sw.� MAIL c� +� /l First 20' •�� ADDRESS ' •-e CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.� Additional a' CITY Tel No. COMPENSATION INSURANCE > PLAN CHECK rL (This section need not be completed if the work.involved APPLICANT 20 Fi Fixtures i h by the'permit is for Lighting xtures rsVone.hundred dollars ($100) or less.) LigADDRESS Total No._Y Additional O I certify that in the performance of the work for which this CITY Tel No. permit is issued, I shall not employ Fixed Appliances Not Over 1 HP H p ty an p' y person in any manner PERMIT W so as to became subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT a Oven _ Dryer_W.M._ ADDRESS ��PO � Date Applicant, Top _ FAU _W.H.._ p Hood — Fen! _Other— CIT S I No T� NOTICE TO APPLICANT: If, after making this Certificate of Disp. doom Air Cond. �Q j LICEN E OR +� Exemption, you should become suliject to the Workers' �' REG.NUMB.ER;L Q Class f^— 110 Compensation provisions of the Labor Code,you must forth- Power-Apparatus&Large Appliances DISTRICT NO. P �CEStp,113 BY with comply with such provisions or this permit shall'be deemed revoked. Size&Type HP,KW,KVA,or KVAR Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE .LICENSED CONTRACTORS'DECLARATION ° Over 10 to 50 Incl. VALIDATION .I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL ' 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY ness and Professions.Code,and my license is in full force and effect. Services License Number 3D Lic.Class ! r� -/d 0-200.Amp.Under 600 V 66 1 Z O - I 201-1000 Amp.Under 600V , Contractor Date. /�- 'a Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit.additional Sign Branch Circuits. ' License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): Misc.Conduits&Conductors ' ❑ I, as owner of the.property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction fending agency for the performance of the work for which this permit is ' 'PERMIT FEE (Sub-Total) 1A # o p o o 2 issued.(Sec.3097,Civ:C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) o o,3 k 6 0 Lender's Address �y PERMIT ISSUING FEE A 0 3 j�6(,v I certify that I have read this application and state that the TOTAL FEE 1 O 1Jc._ 0 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 propp3ty for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE a - S gnature of Permittee ;ipDate , WORKER S'COMPENSATION DECLARATION 76AS6G (2-80) - APPLICATION FOR ELECTRICAL PERMIT +l . hFrebym that I have certificate of consent to self COUNTY OF LOS ANGELES /� BUILDING AND SAFETY insure,on a a cecertificate of Worker rs'Compensation Insurance,or a rti� ere f(Sec.3800,La �O j j FOR APPLICANT TO FILL,IN JOB Poytcy o. Company ds • New Residential Bldgs:&Pools EACH NO. FEE ADDRESS�37, PaCl 'p r G ❑ Certified copy is hereby eurnished. 1 &2-1 amily,Sq.Ft. $ — Is LOCALITY Multi-family Sq. Ft. NEAREST Certified copy is filed with the county building inspection CROSS ST A-department. LAW Residential Swimming Pools OWNER OR Date �a-J Applicant R01� r FIRM NAME 42 V Outlets: RecIlLight Sw.� J Q MAIL. First 20 _ ADDRESS 3me- at-IN ) ed< CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.""� Additional CITY "T �IQ. Gi 7�' Tel No.Ct�Zg sD—�B }' WTr COMPENSATION INSURANCE PLAN CHECK o- APPLICANT J O (This section need not becompleted if the work involved by the permit is'for one hundred dollars ($100) or less.) Lighting Fixtures First 20 Total No. Additional ADDRESS I O I certify that in the performance of the work for which this CITY Tel No. f. Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT W so as to become subject.to the Workers!Compensation Laws. Range_Heater D.W._ APPLICANT iJV d Overi _ Dryer_W.M._ ADDRESS to JB^. �® ��5 �� Date Applicant Top _FAU W.H.._ 4BY Hood _ Fen _Other— �j CITY ,�� R� Tel No.33 NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond._ i�v O( LICENSE.O,R Exemption, you should become subject to the Workers' REG.NUMBER 'S•-J 1 Class 13-11 Compensation provisions of the.Labor Code,you must forth- Power Apparatus& Large.Appliances DISTRICT NO. P C . SBwith comply with such provisions or this permit shall be 'deemed revoked. Size&Type HP,KW,KVA,or KVARUp to 1 Incl. FINALOver 1.to 10 Incl. DATE � /L1 VALID LICENSED CONTRACTORS DECLARATION Over 10.to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL / 9 (commencing with Section 7000)of Division'3 of the Busi- Over 100 BY 'p, ness and Professions.Code,and my license is in full force and effect. Sery �t J 4 ' ',Y�� (0-200 Am�.Under 600 V C,�,tce se umber Lic.Class 201-1000 Amp.Under 600 V ontr for _ 4 ate "7 2 3 Z) Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole.&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Brancl�Circuit License Law for the following reason (Section 7031.5, Busi- Additional.Sign Branch Circuits ness and Professions Code): Misc.Conduits&Conductors ❑ I., as owner'of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not ilitended or,offered for sale (Section 2 2 lj'$A 7044,Business and Professions Code). CONSTRUCTION LENDING.AGENCY I hereby affirm that there is a construction lending agency #. 0 0 0 0. 02 for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec.3097.,.Civ.C.). - 2 o - 3520 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address – 0 0 0 3 5 t (1 PERMIT ISSUING FEE 09.23-80 I. certify that I have read this application and state that the TOTAL'FEE �. above information is correct.Iagree to comply with all County .ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon e abovenenteci �erfor inspection purposes. GL.Ly` c /J SEE'REVERSE FOR EXPLANATORY LANGUAGE 14�Signatureo Permi ee Date ,