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Home My Public Portal About5241 MCCLINTOCK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q I Hereby affirm that I have a certificate of consent to self cE_eoaG insure, or a certificate of Workers'Compensation Insurance, I COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certifjed copy thereof(Sec. 3800; Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB 'Z- d1A . 11 Q„y� Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS !l M 1`-+`fL_1y�J $ ._ $ LOCALITY�E A� L Certified copy is filed with The county building inspec- 1 &2-Family, Sq. Ft. .___ 1 K.•t'� E CA--( tion department. Multi-family Sq. Ft. NEAREST fr_(?CROSS Residential Swimming Pools OWNER OR Ind I�� Date Applicant FIRM NAME I9iV�/K'1L-x C! Ci1`'L�I� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light f/ Sw. MAIL COMPENSATION INSURANCE () Q First 20 ADDRESS (This section need not be completed if the work involved by CITY Tel. No. the permit is for one hundred dollars($100)or less.) Total No. Additional PLAN CHECK (�� I certify that in the performance of the work for which this APPLICANT Q(2E 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 / ADDRESS 5-2iq 6)1AJ1rqi, Pk- y Additional Dote Applicant Total No. _ CITY VLEA y Tel. N Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION 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. — Class. REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. SSED BY a and Professions Code,and my license is in full force and effect. Size&Type HP, KW, KVA, or KVAR O License Number Lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATEgi VALIDATION 0 Over 10 to 50 Incl. FINAL ~ I am exempt under Sec. Over 50 to 100 Inc. BY U W B.&P.C. for this reason Over 100 d ® Services, Swbd., MCC&Panelboards Z Date: 0-200 Amp. Under 600 V I Z 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 1 herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit T P HL-k• a Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits _ Professions Code): LTJ I, as owner of the property, will do the work and the Misc. Conduits&Conductors - I C'-+ - s = i�• structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— I _ Business and Professions Code). ® i I!HL t'm m a CONSTRUCTION LENDING AGENCY �ii 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) L•�mr.ilit °!i (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE ov - Lender's Address TOTAL FEE A r I certify that I have read this application and state that the I � above information is correct. I agree to comply with all County Zo rdinanc s and State laws regulating Electrical wiring, and r orize p ntatives of this County to enter upon th abo - tl r erty for inspec ion p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o P e LDate ®' 1 e WORKERS'COMPENSATION DECLARATION 7&MW DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q •I reby affirm that I have a certificate of consent to self CEs MW ins e, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES I DEPT. OF PUBLIC WORKS or a ovified copy thereof(Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN j ,JOB / �jL °1G/� r ek/' ertiiecopy is hereby furnished. ✓C. ❑Cfd hb � New Residential Bldgs. & Pools EACH NO. FEE ADDRESS_ i '��M pL€ ❑Certified copy is filed with the county building inspec- �. 1 &2-Family, Sq. Ft. $ $ LOCALITY C tion department. Multi-family Sq. Ft. INEARECEASES T. Residential Swimming Pools OR t n Date Applicant OWNER NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS Sa y I �'1L G�ir,TdLl� ✓{ (This section need not be completed if the work involved by First ti CITY the permit Is for one hundred dollars($100)or less.) Total No. Additional 'HECK P C�� Tel. N . v-0 a PLAN CHECK p I certify that in the performance of the work for which this I APPLICANT ��/S Cnl S/ D 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 IADDRESS Total No. Date Applicant Additional CITY Tel. No.I i Fixed Appliances Not Over 1 HP PERMIT p NOTICE TO APPLICANT: If, after making this Certificate of'. APPLICATION Exemption, you should become subject to the WorkersRange— Heater—D.W. _ i 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. ROCESSED BY >_ and Professions Code,and my license is in full force and effect. Id Size 8 Type HP, KW, KVA, or KVARI Q License Number Lie. Class Up to 1 Incl. I FINAL / U Over i to 10 Incl. I DATE "�! VALIDATION Contractor Date I Over 10 to 50 Incl. / O IDIFINAL U I am exempt under Sec. I Over 50 to 100 Inc. BY LLl B.&P.C. for this reason I Over 100 14 d Services,Swbd., MCC&Panelboards Z Date: i 0-200 Amp. Under 600 V , Z Signature I 201 - 1000 Amp. Under 600 V ❑ i Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V I SINGLE FAMILY Temp. Power Pole&Appurtenances iI:i t;i,: (_ HOME OWNER-BUILDER DECLARATION 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 Professions Code): I • ; "ITAL 31 .00 ® I, as owner of the property, will do the work and the I Misc. Conduits&Conductors -,'- F:ti'� =s.!li structure is not intended or offered for sale(Section 7044, ! Other(See Complete Fee Schedule)_ Business and Professions Code). , CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for rl )i j jthe performance of the work for which this permit is issued PERMIT FEE (Sub-Total) I L- (Sec. 3097, Civ. C.). I I 492_7 i4 n i PLAN CHECKING FEE Ail Lender's Name I PERMIT ISSUING FEE Lender's Address I TOTAL FEE I certify that I have read this application and state that the J/ dP above information is correct. I agree to comply with all County I ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned proper for inspection purposes. ( SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of firermlifee Dbte I ®'