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Home My Public Portal About10206 OLIVE ST_Electrical__ WORKtR'S COMPENSATION DECLARATION 200.001 DPW(12-91) 1 I hereby affirm that I have a certificate of consent to self-,sure, APPLICATION FOR.ELECTRICAL PERMIT or a certlPate of Oorker's Compenlation Insurancl, oil a c 'lfied COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C:) Policy No. Company FOR APPLICANT TO FILL IN JOB NOEACH ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools . FEE LOCALITY ❑ $ $ Ft S Certified copy is filed with the county building inspection 1 &2-Family, q. . —_ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' � �' OWNER OR n COMPENSATION INSURANCE lets: ec Light Sw. a.�cy OA;K FIRM NAME {��✓�First 20 (This section need not be completed 0 the work involved by the Total No. �'"�"�47 Additional ADDRESS �Ze permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY ,a,V�,CV Tel.No. is issued, I shall not employ any person in any manner so as to OO PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making 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 PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT ": LICENSED CONTRACTORS DECLARATION Size&&T�KW,KVA,or KVAR / ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)of Division 3 of the Business and / C CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl, >_Over 50 to 100 Incl. LICENSE Class REG.NUMBB ER d License Number Lic.Class Over 100 DISTRICT NO. PR SSED BY 0 Services,Swbd.,MCC&Panelboards 0-399 Amp.Under 600 V FINAL Contractor Date DATE ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V 10_,� VALIDATION V Over 1000 Amp.or Over 600 VW FINAL B.&P.C.for this reasonBFtANCH CIRCUIT FEES BY CO Date: 15A,or 20A,120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,MA,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit IN&nr 138 a 41D.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 KpT?f7Rih �Afl Cod �1��++4r 41 I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors CHAWE TTENS .00 is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) , I ,I" r. , and Professions Code). 0000-000"1 12/29/95 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 3998 1 TP:14 performance of the work for which this permit Is issued(Sec. 3097, PERMIT FEE (Sub-Total) G' Civ.C.) PLAN CHECKING FEE Lender's Name • PERMIT ISSUING FEE � � L7 Lender's Address TOTAL FEE I certify that I have read this application and under penalty of purjury state that the above information is correct. I agree to comply with all County ordinances.a�id State laws regulating Electrical wiring,and hereby authorize repres latives of thislCounty�p enter upon the above-mention d property fbr'Ifispection purpo I / 10 SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNenl5rciF PERMITTEE DATE a 1 WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT 78A663 I hereby affirm that I have a certificate of consent to self lure, ° or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thh�ereof ec. BOPL be C.) Policy No. Company f / FOR APPLICANT TO FILL IN A NO. ADDRESS C ❑ EACH FEE .Certified copy is hereby furnished. New Residential Bldgs.&Pools LOCALITY � $ $Ft S il Famy, q. . _ Certified copy is filed with the county building inspection 1 &2- NEAREST d/e},�rtme t. /� Multi-family Sq.Ft. CROSS ST. C Date `� r Applicant •� ✓►"J f Residential Swimming Pools ASSESSOR PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. ht Li �Sw. p sf FIRMENRAME n COMPENSATION INSURANCE g First 20 /�V �/ (This section need not be completed If the work Involved by the � ADDRESS permit Is for one hundred dollars($100)or less.) Total No. Add'iU I I certify that in the performance of the work for which this permit CITY - el.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures JFIrst 20 APPLICANT Total No. ditional ;OpADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation I OTHER APPLIANCES NOT OVER 3 HP. PERa/ IT provisions of the Labor Code, you must forthwith comply with such power Apparatus&Large Appliances APPLICANT provisions or this permit shall be deemed revoked. n LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)of Division 3 of the Business and CITY �� fe1.No. i Over 10 to 50 Incl. Professions Code,and my license is in full force and effect. LICENSE OR �l Over 50 to 100 Incl. REG.NUMBER V Class' �"" � U License Number ` ! Lie.Classver 100 DISTRICT NO. PRO SED BY P el Contractor Date / " BeSe c ,Sw� Amp UP FINAL pJa�ds �7 DATE O ❑ 400-1000 Amp.Under 600 V S VALIDATION W I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL Il B.&P.C.for this reason BRANCH CIRCUIT FEES BY C0 Date: i 15A,or 20A,120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits _ SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION `c I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ____ for the following reason (Section 7031..5, Business and Professions Additional Sign Branch Circuits 3: Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 71-17 Ai , 5 is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Sched e) i i;;_.y-y, tr o _ and Professions Code). CONSTRUCTION LENDING AGENCYI I hereby affirm that there is a construction lending agency for the il;Nl]t: ° performance of the work for which this permit is Issued(Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE 0_1 Lender's Name PERMIT ISSUING FEE Lender's Address / I certify that I h Ye read this applicati and under penalty of purjury state TOTAL FEE �O that the abov Information is corre e I agree to comply with all County I ordinances State laws tin ectrical wiring,and hereby uthor e represent es of this C ty t r upon the above-men 10 d pro rty ' for insp Io purposeWe) SEE REVERSE FOR EXPLANATORY LANGUAGE T E OF PERMITi OA I