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Home My Public Portal About10619 OLIVE ST_Electrical__ ° WOR 111'q,;COMP,ENSATION DECLARATION 20-0019 DPW(72•.91) ' t„ 7. X663 APPLICATI - N .F��R ELE TRI.CAL. PERMIT I.hereby af:fifl'n:that I have a.certificate of consent to self insure,. QI�r,�N, FOR a certificate df Worker's Compensation Insurance, or a;certified COUNTY OF LOS ANGELES ,SEPT.OF PUBLIC , ORKS BUILDING AND SAFETY DIV. copy theNof(Sec.'3800 Lab.C.) 'Policy No.3AQ6-94 Company. S TfTE' rL 7/ b . I FOR APPLICANT TO FILL IN ADDRESS NO'. EACH FEE °❑ 'Certified copy is hereby furnished., � New Residential Bid s.&'Pools �� OL.�Vg � g LOCALITY ❑ 1&Z-Family,.Sq.Ft..- _ $ .$ I - T& '1 '�' 7T Certified copy is filed with:.the county building inspection l (,NEAREST department. 1 Multi-famlly'Sq.Ft. CROSS ST., fl.j/LS Residential Swimming Pools (ASESSOR Date• — •'9� Applicant i (. SMAP BOOK ?jp PAGE IJ340 1 PARCEL 40.7A CERTIFICATE-OF EXEMPTION FROM WORKERS" .ItOWNER OR Outlets:Rec.—Light - Sw. I FIRM NAME COMPENSATION.INSURANCE t (THis section need not be completed if First.20 170hiL the work Involved by the I ADDRESS permit is for one hundred dollars($100)or less.) Total No. Additional /do N• R XJA.NG19 Sl-Ar IY •14da I Certify that in the performance of the work.for which this permit i 'CITYTel.No: Jis-" is issued, 1 shall not employ any person in any'manner•so.as to '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 TeI.:No. Exemptidn,,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. `PERMIT provisions of the Labor Code,you must forthw , ith comply with such APPLICANT provisions.or.this permit shall be deemed revoked. Power Apparatus&Large Appliances f' /9'A j&i71j.,VA/ D r Ar7v7 LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR i ADDRESS 446 ^+ i hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. ` Tali No:_ (commencing with Section 7000)of Division.3.of the.Business and jCITY 44V-40'76 Over 10 to 50'Incl. Professiohs Code,and my license is in.full force and effect, ,. _ - - � M LlcenjsE oR.. •• � Over 50 to 100 Incl. ,,REG.NUMBER .G 7./3 a Clens, " QO Over 100 "DISTRICT NO. SSED BY License Number to 77 13AIX iic,Class. &-.l V Services,Swbd.,MCC'&Panelboards 'elf 0 Contractor'�'F• b"ff1OPh67VZ to 3:0 �4� 0-399 Amp.Under 500 V FINAL 406 1000 Amp.Under 600 V ! PATE V 0 I am axempt under Sec: VALIDATION W. Over 1000 Amp.or Over 600 V FI AL a B.&P.C.for this reason. BRANCH CIRCUIT FEES co Date: 15A,or 20A,'120V,Lighting or'Recept. 1 To 10 Branch Circuits Signature- 11 To 40 Branch Circuits 41 Or More Branch Circuits sy nemption for Reg.Meint.Elect. 15A,20A,208V'To 277V Lighting Br.Circuits J.. .4 SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION P PPS'' `°v Sign with One Branch Circuit �. 1 hereby affirm that I am exempt from the Contractor's License Law 89.85 for,the following:reason (Section 7031.5,,Business and Professions ? Additional Sign Branch Circuits Code): ❑ I,as owner of the property,will do.the work and the structure Misc..Condu.its&Conductors + 5 P P Y 1 L 8 qua-.: is not Intended.or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). I CHECK 339 R.M CONSTRUCTION LENDING AGENCY CHANGE °ula 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) Civ.C.) 000,01-000 1. 3/2411954 PLAN CHECKING`FEE Lender's Namea I 9616 1 Al11°06 PERMIT ISSUING FEE Lender's AddressI I certify that I.have-read this application and under penalty of purjury state 1 TOTAL FEE 0ev a, O that the above information is correct. I agree to comply with all County r , ordinances and State laws regulating Electrical wiring,.and hereby authorize representatives of this County to enter upon the above-mentioned property for Inspection purposes. i SEE REVERSE FOR EXPLANATORY:LANGUAGE i t SIGNATURE OF PERMITTEE DATE • t WORKER'S COMPENSATION DECLARATION 2D-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT L1 76A663 I hereby.-affirm thea I•have'a certificate of consent to self insure, or a,sertificate of Worker's Compensation Insurance, or a certified' COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) FOR APPLICANT TO FILL IN JOB Policy No. Company ADDRESS -Certified copy is hereby furnished. New Residential Bidgs.&Pools O.I EACH FEE• OCALITY ❑. 1&2-Family,Sq.Ft. _ $a $ Certified,copy is.filed with the county building inspection ll NEAREST department. Multi-family Sq.Ft. CROSS ST. °( Date Applicant Residential Swimming Pools ASSESSOR PAGE. PARCEL MAPBOOK CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Li ht Sw. FlRMENAME • COMPENSATION INSURANCE I g ��'��' �U ��' Fust 20 WAIL �� e� , / �� (This section need not d completed if the work involved by the Total No. Additional `' • ADDRESS J ��CV permit is for one hundred dollars(9100)or less.) l I certify.that in the performance'of.the work for which this permit CITY Tel.No. �2.,� 7.00 is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation LawsLighting Fixtures First 20 APPLICANT I .S� a 7� L dve C.�o r dg(�/`, Total No., Additional ADDRESS Date t 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. rovisions of the Labor Code,you must forthwith comply with such PERMIT 1 P Y P Y APPLICANT 4r provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances 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 c� LG Tel.No. Professions Code,and m license is in full force and effect. Over 10 to 50 Incl. LICE } y. REG. N MB �.^1 Pi� Class. �.�(® O ' Over 50 t0 100 Incl. REG.NUMBER L /f `L IL Over 100 DISTRICT NO. PROCESS Y License Number �� Lic.Class �� U a Services,Swbd.,MCC&Panelboards Contractor�P✓f e Jae d eWate 5t1d 0-399 Amp.Under 600 V DAA U ❑ 1 am exempt under Sec. 400-1000 Amp.Under 600 V V.'�G"q� VALIDATION Over 1000 Amp.or Over 600 VI _ FINAL IL B.&P.C..for this reasonBRANCH CIRCUIT FEES BY co Date: S ! S _15A,.or 20A,120%Lighting or Recept. 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 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 Sign with One Branch Circuit l hereby affirm that I am exempt from the Contractor's License Laws for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 02 ; ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors s is not intended or offered for sale(Section 7044, Business' Other(See Complete Fee Schedule) AC(i .a and Professions Code). i , � 330 CONSTRUCTION LENDING AGENCY ITEMS 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) TOT.A ' 3 1-7 G 8(3 Civ.C.) I PLAN CHECKING FEE CHECK Lender's Name PERMIT ISSUING FEEeCHANGE °00� Lender's Address TOTAL FEE I certify that I have read this application and under penalty Of purjury state I / that the above information is correct. 1 agree to comply with all County ordinances and State laws re ulating Electrical wiring,and hereby authorize '+E;# representatives this Cou to enter upon the above-mentioned property, � � � Ja �a_r for insp n p rp sea. SEE REVERSE FOR EXPLANATORY LANGUAGE 0476 1 AM 10:32 S itetp SIGNA E OF PERMITTEE -DATE