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Home My Public Portal About5219 PAL MAL AVE_Electrical__ WORKERS',COMPENSATIONDECLARATION ICE-806G (2.80) APPLICATION FOR ELECTRICAL PERMIT E•SO6 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'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) v� Policy No. Company. FOR APPLICANT TO.FILL IN JOB �r /I '1' � 6„ New Residential Bldgs.&Pools EACH NO. FEE ADDRESS /� 114- 1- Certified copy is hereby furnished. 1 &ZFamily.Sq. Ft. $ — $ LOCALITY rte.dot-- C ❑ ' 1 Multi-family Sq'. Ft. — EAREST �^ Certified copy is filed with the county building inspection CROSS ST _,:'M cG 12� depart _ Residential Swimming Pools Date p Applicant FIRM NAME !/V l 4 L rTrv�l R L �C G PP Outlets: Rec.^Light First ADDRESS a tv6OtcP—C) to First 20 ,CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY �tylNo' o.,�7 Lit-1 •q 2 } COMPENSATION INSURANCE CL PLAN CHECK—. ('this section need not be completed if the work involved APPLICANT0 by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS5 , + Total No. Additional O I certify that in the performance.of the work for which this CITY Tel No. permit is'issued, I shall not employ any person in any manner Fixed Appliances Not Over 1 HP PERMIT f .-,, c so as to become subject to the Workers'Compensation Laws. Range_Heater D.W. _ APPLICANT of ry U M Oven _ Dryer_W.M._ ADDRESS Date—L—0 D Applicant t/�/O�� v ( Top _F.AU _W.H. Hood _ Fan _Other_ CITY . Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp.. _Room Air Cond— LICENSE•OR TML�P Exemption, you should become subject to the Workers' REG.NUMBER lass G L� Compensation provisions of the Labor Code,you must forth- 11 Power Apparatus&Large Appliances DISTRICT NO. PR BY with comply with such permit shall be • p provisions or this 1 Size&Type HP•,KW,KVA,or KVAR P eq deemed revoked. it UIS to 1 Incl. FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 1.0 Incl'. DATE ,I VALIDATION • 1 Over 10 to 50 Incl. • I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 9 (commencing with Section 7000).of Division 3 of the Busi- I Over 100 lG� ness and.Professions.Code, and my license is in full force and effect. - Servic f�A� ' License Number 0 C—�0 ' 0-200 Am nder 600 V !� Lic.Class -. Amp.Ugder 600 V Contractor a•P!` Date 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 I:Sign with One Branch.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 intended or offered for sale (Section i 7044,Business and Professions Code). i CONSTRUCTION LENDING AGENCY ;?364,2P I hereby affirm that there is a construction lending agency for the performance of thework for which this permit is PERMIT FEE (Sub-Total) �f o 0 0 a G2 issued(Sec.3097,Civ.C.). M `�� AI Lender's Name 'by� PLAN CHECKING FEE (One-Fourth Permit Fee) 2 0 0 1 9,50 Lender's Address PERMIT ISSUING FEE 0 0 0 1 Q 5 WE a I cgtify that'I have read .this application and state that the. TOTAL FEF, 0 .1,0 b•—8 1 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-mepfioned pro arty for' spectiuoses. I Fon purposes. M.s ' SEE'REVERSE FOR EXPLANATORY LANGUAGE L_G `fid Signatu .of Permitte Date WORKERS'COMPENSATIONDECLARATION ICE-8066G (2.80) APPLICATION .FOR ELECTRICAL PERMIT - 4 CE-8 , I hereby affirm that I have a certificate of consent to self ) COUNTY OF LOS ANGELE BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) 1 Policy No. CompanFOR APPLICANT TO FILL IN JEACH NO. FEE ADDRESSJOB � MA. y New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ 1 LOCALITY Multi-family Sq. Ft. — NEAREST Certified'copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: Rec.I Light Sw. MAIL , 2 Af 6 CERTIFICATE OF EXEMPTION FROM WORKERS' First ADDRESS Total No. Additioonal CITY L F~� L Tel No. ' ZL a COMPENSATION INSURANCE PLAN CHECK O (This section need not be completed if the,work involved. gPP'L.ICANT 0 First 20 e t Fi Lighting by the permit is for one'hundred dollars ($100) or lessg xurs.) LigADDRESS OC - Additional Total No•. U I certify that in the performance of,the work for which thisCITY Tel No. , Fixed Appliances Not Over 1 HP permit is issued, I shall not employ anypqrson in any manner PERMIT YL,c- so as to become subject to the Worker omp ti r Laws. Range_HeateD.W._ APPLICANT L I /d/ ( 0 2 fi Oven _ Dryer_W.M._ ADDRESS "2 Z Dat ApplicantVTop ._FAU _W.H..._ Hood _ Fan _Other_ CITY'` L .G Tel No. ( [�� NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond,_ LICENSE OR ��0 L� / Exemption, you should become subject to the Workers' REG.NUMBER l� Class Compensation provisions of the Labor Code,you must forth-� Power Apparatus& Large Appliances DISTRICT NO. PROC D 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. VALIDATI 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' 0-200 Amp..Under 600 V License'Number Lic.Class 2201-1000 Amp..Under 600 V Contractor Datei Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances ' I herebyaffirm that I am exempt Sign with One Branch Circuit , mpf from on Contractor's Additional Sign Branch Circuits License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ` Misc.Conduits&Conductors 1, as owner of the property, will do the work and the Other(See omp te.F e cYSed e1— 4 2 6 9 A structure is not intended or offered for sale (Section I 1 (j 7044,Business and Professions Code). -CONSTRUCTION LENDING AGENCY # 0 0 0 0 0 2 I hereby affirm. that there. is a construction lending agency 20607.50 0 0 0 �.5 , for the performance of the work for which this permit is �PERMIT FEE (Sub-Total) issued(Sec.3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 00007.5050 . Lender's Address PERMIT ISSUING FEE 03.02-81, '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 t ordinances and State laws regulating Electrical wiring, and 1 hereby authorize representatives of this County to enter upon – 4ve-md�iioned o erty for inspection purposes. ISEE-REVERSE FOk EXPLANATORY LANGUAGE f Permittee Date WORKER'S COMPENSATION DECLARATION 20.001 DPW(12-91) P, 6AO63 +.hereby affirm ttilt.a have a certificate of consent to self insure, APPLICATION FOR ELECTRICAL PERMIT or a certificate of Wor'ker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy tkreof(Sec.3800 Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS 9 A L %h at L Certified.copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY ❑ Certified.copy is filed with the county building-inspection 1&2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming.Pools ASSESSOR p G �qq�� MAP BOOK a G PAGE r�PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.e�Light Sw:� p FIRM NAME '" 4K COMPENSATION INSURANCE ,d'� First 20 MAIL (This'sectlon need not be completed If the work Involved by the permit Is for one hundred dollars($100)or less.) Total No. Additional (� ADDRESS , Z - �l ft certify that in'the performance of thalwork.for which this permitp CITY er^ Tel.No: is Issried, I'shall riot employ any person in any manner so as to Ob D� PLAN CHECK become subject to the Workers'Compens ion Laws. Lighting Fixture First 20 G APPLICANT' Total No. Additional �1 E ADDRESS Date �" ApplicantRESIDENTIAL APPLIANCES NOT OVER 3 HP. N.OTI TO PPLICANT: If, after mak— is Certificate of CITY Tel.No. xempEt in on,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 H.P. provisions of the Labor Code,.you must forthwith comply with.such PERMIT f7provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT%_)1,L1 OAj LICENSED CONTRACTORS DECLARATION Size&&Type HP,KW �c,�Or KVAR ADDRESS 0 2 I hereby affirm that I am licensed under provisions of Chapter 9 '1. l'3.dfe►.rr.�//334/o l0 IncI. (commencing with Section 7000)of Division.3 of the Business and CITY 0,� Tel.No. rte+ Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. } LICENSE OR Over 50 to 100 Incl. REG.NUMBER q 7 Class. O _ O Over 100 DISTRICT NO. PRO SED BY U License Number & Lic.Class n �O O Services,Swbd.,MCC&Panelboards `� d Contractor Date & �' 0-399 Amp.Under 600 VAMD S DATE O ❑ I am exe pt under Sec. 400-1000 Amp.Under-600 V y W Over 1000 Amp.or Over 600 V FINAL ` VALIDATION d B.&P.C,for this reason. BY • BRANCH.CIRCUIT FEES Date: 15A,or 20A,120V,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 ACCT HOME OWNE13-BUILDER DECLARATION Sign with One Branch Circuit 4 I hereby affirm that I am exempt from the Contractor's License Law 310 265.5.811for the following reason (Section 7031.5, Business and Professions Additional.Sign Branch Circuits Code): . .. .- �t 1IT� S r_1 • I,as owner of the-property,will do the work and the structure Misc.Conduits&Conductors _ .... ._. 268=0 813 is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL '� � and Professions Code). •• ''CHEM .�' 8065 e CONSTRUCTION LENDING AGENCY " ' CHANGE a011 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) C/ 5 Civ.C.) PLAN CHECKING FEE U � 1 1 6/276 93 Lender's Name ) AM11%1a PERMIT ISSUING FEE p2 Lender's Address I certify that i have read this application and under penalty of purjury state TOTAL FEE that the above information is correct: 1 agree to comply with all County 4represetives d State laws regulating Electrical wiring,and hereby authorize of this County to enter upon theabove-mentioned property purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE a3EB M" 0A WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT L1 ' I hereby affirm that I have'a certiftbate of consent to self insure, 76A663 or a certificate 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.) Policy N0. Company FOR APDL CANT'TO FILL IN JOB >ry , ADDRESS ✓ 60 Certified copy is hereby furnished. New Residential Bldgs.&Pools NO.1 EACH FEE LOCALITY .� ❑ 1&2-Family,Sq.Ft. _ $, $ t Certified copy is filed with.the county building inspection NEAREST departm_ent. Multi-family Sq.Ft. CROSS ST. Residential Swimming Pools ASSESSOR Date Applicant t'; A IutAP BOOK dam/O PAGE PARCEL �J CERTIFICATE OF EXEMPTION FROM WORKERS' �r ` '` OWNEROR COMPENSATION INSURANCE Outlets:Rec. Lights 'L Sw. ,'_ '+ FIRM NAME First 20 x MAIL (This section need not be completed If the work Involved by the Total No. Additional "rADDRESS �� rYb� permit Is for one hundred dollars(8100)or less.) I certify that in the performance of the work for which this permit CITY �'j Tel.No. is.issued, I shall not employ.any person in any manner so as to become.subject to the.Workers'Compensati Laws. Lighting Fixtures First 20 PLAN CHECK APPLICANT Total No. 3 Additional -ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. �'3 NOTI E TO APPLICANT: If., afte makln t Cer ificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. rovisions of the Labor Code, ou must forthwith.com I with such PERMIT p y I?y e A r &L t r Apparatus Large APPLICANT(,77 G �� p 'provfsidns or this permit shall be deemed revoked. P 8 , LICENSED-CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 7 0-W 49- Z/ZdZV1j , 1-hereby affirm that I am licensed under provisions of.Chapter 9 Over 3.to101nci. byaw (commencing with Section 7000) of Division 3 of the Business and CITY Gam' Gt Tel.No. Professions Code,and my license.is in full force and effect. Over.1P to 50 Incl. LICENSE OR } 6 Over 50 to 100 Inbl. REG.NUMBER ,� Over 100 DISTRICT NO. P CE ED BY 0 License Number � Lic:Class Sll`LT� V Services,Swbd.,MCC&PanelboardsFINAL ContractorDete 0-399 Amp.Under 500 V DATE 0 ❑ l 400.-1000 Amp.Under 500 V I am exempt under Sec. FINAL VALIDATION d Over 1000 Amp.or Over 600 V B.&P:C.for this reason B9ANCH CIRCUIT FEES BY z Date: 15A,or 20A,12OV,Lighting or Recept. _ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Matnt.Elect. 15A,20A,208V.To 277V Lighting Br.Circuits "y A SINGLE FAMILY Temp;Power Pole&Appurtenances n(+ s HOME OWNER-BUILDER DECLARATION ACCT o 4 I hereby affirm that I am exempt from the Contractor's License.Law Sign jvtth One Branch-Circuit - 7 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 33603 f r° =1 Code): i ITEMS ❑ 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors .R is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL 7 a .o 0 and Professions Code). CHECK, 77.70 CONSTRUCTION LENDING AGENCY 'CHANGE• .0 11 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.) _ PLAN CHECKING FEE UOS�3-171131 f/ f/a1 Lender's.Name / PERMIT ISSUING FEE (.0 0964 . 1 All 9°ILf Lender's Address TOTAL FEE I certify that-1 have read this.application and under penalty of purjury state �. that the above information is correct. I agree to comply with all County ordinances nd State laws regulating Electrical wiring,and hereby authorize represent Ives of this County to enter upon.the above mentioned property 4inspen purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ER E D.