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Home My Public Portal About5308 MCCLINTOCK AVE_Electrical__ r WORKERS'COMPENSATION DECLARATION M-0019 Corwsie� APPLICATION FOR ELECTRICAL PERMIT Q 1 hereby affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certifi d coL3y there (Sec. 3800, Lab. C) p Po l' y Nd- 47 Company S FOR APPLICANT TO FILL IN JOB Xd C' Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS fl Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ = $ LOCALITY T.e o LPJ tion epar Qent. 'Old Multi-family Sq. Ft. CROSNEARS ST. PW Date ` Applicant JW r,P.. h Residential Swimming Pools OWNER OR �y FIRM NAME !JC// 0 - CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets: Rec Light Sw._ I ADDRESS 2vV(! �)•� v`� tThis section need not be completed if the work involved b First CITY Tel. he permit is for one hundred dollars($100)or less.) Y Total No. Additional P I certify that in the performance of the work.for which this APPLICANT CANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional Date Applicant Total No. CITY Tel. No. 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 � a with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY (Q/ el. 7 LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. — REG. � Class. I hereby affirm that I am licensed under provisions of Chapter 9 NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSEDdD}.. and Professions Codeand my life a is in full force and effect. V S (�+fL Size 8 Type HP, KW, KVA, or KVAR �O License Number ALic. Class Up to 1 Incl. FINAL e VICIT 5 22 Over 1 to 10 Incl. DATE /� _ VALIDATION 0 Contracto Date Over 10 to 50 Incl. ! U ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W Over 100 IZ B.&P.C. for this reason Services, Swbd.,MCC&Panelboards , U) Date: 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V El Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances coo HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 3• I hereby affirm that I am exempt from the Contractor's License s-1,..: ;e'E• Law for the following reason Section 7031.5, Business and Additional Sign Branch Circuits _ Professions Code): ❑ 1, as.owner of the property, will do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ , __I e Business and Professions Code). CONSTRUCTION LENDING AGENCY ':i IK I hereby affirm th tat there is a construction lending agency for he performance of the work for which this permit is issued PERMIT FEE (Sub-Total) t'fl'-if3'zr (Sec. 3097, Civ. C. PLAN CHECKING FEE Lender's Name 'w #_iiiaC 1 1j l I; iZ: 7i PERMIT ISSUING FEE �� '�? Lender's Address flb , ' r x710131` f AN. I _=t 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 ordinances and State laws regulating Electrical wiring, and :I Ah by authorize repr sentatives of this County to enter upon bove-mention pro y for lnspecti n pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE ®s Signature of rmittee to WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O 1 hereby affirm that I have a certificate of consent to self .cE6 , insure,'or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certifi cC thereo (Sec. 3800, LQ 7� P I' y No Company A , FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY J tion part t Multi-family Sq. Ft. NEARESTCROSS T. cal. LfV ate Applicant 1 Residential Swimming Pools OWNER OR FIRM NAME �I ERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ I MAIL COMPENSATION INSURANCE I ADDRESS 2 (This section need not be completed if the work involved by First CITY 1 Tel. the permit is for one hundred dollars($100)or less.) Total No. Additional SIM �`, � 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 Date Applicant Total No. CITY Tel:•No. Fixed NOTICE TO APPLICANT: If, after making this Certificate of Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION Q u. Compensation provisions of the Labor Code, you must forth- Oven •— Dryer —W.M.— ADDRESS 'Z i) Li ,l with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY �Q/ T LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER 51aCy... (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P SSED BY and Professions de,MdIense is in full force effect. Size&Type HP, KW, KVA, or KVAR rtJ �G �a �-- O License N er oLic. Class Up to 1 Incl. I FINAL U �` 1 I Over 1 to 10 Incl. DATE I—& VALIDATION Er Contracto Date Over 10 to 50 Incl. I FINAL F'" ❑ I am exempt under Sec. Over 50 to 100 Inc. U BY Oer 100 UJ v B.&P.C. for this reason 11 Date: Services, Swbd., MCC&Ponelboords Z 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&Appurtenance s✓ � C7 HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License 1 Sign with One Branch Circuit Branch Circuits n " Law for The following reason (Section 7031.5, Business and Additional Sign e•i+_=.- , Professions Code): ❑ 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). �•�F.• L 4-Z 0L fZ9 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. ). r, �•:�'Itii'itsC ,i13_ Ir PLAN CHECKING FEE+ Lender's Name PERMIT ISSUING FEE Lender's Address12� a �';„" •+ I certify that I have read t.iTOTAL FEE s application and state that the � �� r s:ts: t �l`) above information is correct. I agree to comply with all County , ordinances and State laws regulating Electrical wiring, and y Aheruthorize representatives of this County to enter upon e-mentio rty o inspection rpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE 7 ®� of Per Tfee Daf j WORKERS'COMPENSATION DECLARATION DPW APPLICATION FOR ELECTRICAL PERMIT Q (hereby affirm that I have a certificate of consent to self cE insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS orla certified copy thereof(Sec. 3800, Lab. C.) ^ Policy No Compan, ,l7T/fes Atr I/r FOR APPLICANT TO FILL IN JOB r � � Certified copy is hereby.,furnished. rNewResidential Bldgs. 8Po�ols�,/ EACH. NO. ' FEE ADDRESS ertified co is filed with the count buildin inspec- 6 2-Famil S Fte_A224— $ $ LOCALITY PY Y 9 P Y q• _ t--LP4ion de artmentultNEAREST i-family Sq. Ft. CROSS ST. c;�!�S� Date Applicant ell Residential Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' OutMAIL lets: Rec Light Sw._ COMPENSATION INSURANCE ADDRESS a . tai' 21 (This section-need not be-completed If the work involved by First 20 CIN hhl Tel. No. the permit is for one hundred dollars($100).or less.) Total No. Additional /V tLJ! PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued., I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional i Date Applicant Total No. CIN Tel,No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT ;'� /1 Exemption, .you should become subject to the Workers" Range— Heater—D.W. .L APPLICATION V Compensation provisions of the Labor Codes you must forth- Oven — Dryer W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU W.H. — deemed revoked. Hood Fan —Other— CITY�ftV Tel. No,. LICENSED CONTRACTORS DECLARATION LICENSE OR — �y I hereby affirm that I ani licensed under provisions of Chapter 9 Disp. Room.Air Cond. REG.NUMBER Class. �•�'/ (commencing with Section 7000)of•Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PR SED BY d and Ptofessioris Code,and my lice se is in full force and effect. Size&Type HP, KW, KVA,.or KVAR O License Numb r Lic: Class ` Up to 1 Incl. FINAL U Contractor �� Date—' Over 1 to 10 Incl. DATE 1 _1. 1-&, VALIDATION 0 ❑ Over 10 to 50 Incl. ! 6 FINAL (� I am exempt under Sec. Over 50 to 1'00 Inc. BY ., W B.BP.C. for this reason Over 100 K n- .- C0 Services,Swbd.,MCC 8 Panelboards Z ' Date: 0.-200 Amp. Under 600 V — Signature •201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY y HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that.I am exempt from the Contractor's License Sign with One Branch Circuit AM.o a Law for the following reason '(Section 7031.5, Business and Additional.Sign Branch Circuits Professions Code): .:e30 iL-r a T5 t= I; as owner•of the Property, will do the work and the Misc. Conduits$Conductors 1 ITEMS structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ® TAL 2 14 Business and Professions Code). T01 -75 CONSTRUCTION LENDING AGENCY ;j}j 124.75 1 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) CHANGE (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name / 0I3(1 _(101, 7/ 3191 PERMIT ISSUING FEE Lender's Address7�`4��' r 1 AM 9:ri ' I certify that ITOTAL.FEE. have read this application.and state 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 above-7 tion d property fo inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE h. gnat f Permitt ate ®s