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Home My Public Portal About5540 PAL MAL AVE_Electrical__ WORKERS COMPENSATION DECLARATION 74- ° '31V APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self a sure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS {Lt or a cZ,ed coy thereof(Sec 3800, Lob C ) P h No 3 -73 Company STATE F✓ND. FOR APPLICANT TO FRL IN JOB ^,L7 MCartified copy is hereby furnished New Residential Bldgs 8 I, EACH Fro FEE ADDRESS I- MAL AVC r-1 Certified copy a filed with the county building i 18 2-Family, Sq Ft P S $ = $ LOCALITY tion departments Multi family Sq Ft CROSS ST LIVE O A K• A' q ✓Dote �-2 92Apphcant esidemal Swimming Pools D,,,,� ��77 FIRM NAME CERTIFICATE OF EXEMPTION F WORKERS' outlets RecLLLtght�Sw V— "IL COMPENSATION INSU CE Fust 2070 ?40&0 ADDRESS (This secneed riM be completed If tfi.work Involved bF Total No � Additional CITU N pA /� Tel No -3-T the pp r Is IF for artundrod dollars(5100)or loss) P `O T CO t.1 I cera that in the performance of the work for which this 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 J&6/9 M R PL£Se-o ve AVz Addnioral APP Total No CITY q L N Tel No 17-34 NOTICE TO APPLICANT If liafter making this Certificate of Fixed Appliances Not Over 1 HP EMAPPLICATION s Exemption you should become subject to the Workers Range— Heater_DW Compensation provisions of the Labor Code, you must forth Oven _ Dryer —W M ADDRESS with comply with such provisions or this permit shall be T — FAU —WH — deemed revoked Hood — Fon —Other_ CIN Tel No LICENSED CONTRACTORS DECLARATION asp _ Room Air Cond — LICENSE R NUMBER 676 Class I hereby affirm that I am licensed under provisions of Chapter 9 ( 06 commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO D BY a- -7641 and Professiom Code,and my license is in full farce and effect 4 6 7G ^ I Size 8 Type HP, KW KVA, or KVAR OU License Number 'T Lic Clogs Up to 1 Incl FINAL Contractor RLLi-i C•nAASTCOtuLTn,.?e 1 —!L7-92 , Overlto 10 Ind DATE ,Z Z VALIDATION ECO ❑ Over 10 to 50 Incl FINAL f- 1 am exempt under Sec Over 50 to 100 Inc BY W B BP C for this reason Over 100 ,� a Services,Swbd ,MCC 8 Ponelboards Z► t Z Date 0 200 Amp Under 600V Signature 201 1000 Amp Under 600 V - ❑ Over IOOO Amor Over 600 V T�-M; p Exemption for Reg Main? Elect 1 C SINGLE FAMILY Temp Power Pole 8 Appurtenances f f j i AL 84 - 01 HOME OWNER BUILDER DECLARATION Sign with One Branch Grant ll'L�l{ ?/t.1_1 I hereby off irm that I am exempt from the Contractor's License Additional Sign Branch Circuit Low for the following reason (Section 7031 5 Business and g ` ••t '�I- Professions Code) - ❑ 1, as owner of the property will do the work and the Mise Conduits S Conductors structure is not intended or offered for sole(Section 70" Other (See Complete Fee Schedule)- 01111. I'_I'I_I�Ql,ill 2/20/52 Business and Professions Code) CONSTRUCTION LENDING AGENCY 19Q4 1 AM i.I:f1= I hereby offum 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, Cry C ) PLAN CHECKING FEE Lender s Name PERMIT ISSUING FEE Lenders Address I certify that I have read this application and state that the TOTAL FEE Q above information is correct 1 agree a comply with all County ordinances and Sate jaws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mention pro rty for impaction purposes SEE REVERSE FOR EXPLANATORY LANGUAGE f m. Signa of r Permittee Date TION WORKER I have corlAcite of DPW 9189 APPLICATION FOR ELECTRICAL PERMIT I hereby elllrm that I have s certilicata of content to sell Insure ar a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sac 3300 Lab C) poky NO Company FOR APPLICNR TO FILL of ADDRESS aAlv 5 1:1 certified copy u hereby huNew Residential NResidential Bldgs 8 Pods EACH NO FEE ❑ � ih Ned with the county building Fl LOCALITY moi Mutd-IamM So Ft r EST GR a 8T f v� Date Applicant Residential Swimming Pooh ASSESSOR MAP BOON PIE PA CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec _Light_Sw RAS v COMPENSATION INSURANCE (This wctlon need not be rxwnplated If the work Involved by the First 20 permit Is for one hundred dollen($100)or leu) Total No Additional l c5 I certify that In the performance of the work for which this permit / To, Ib _ is Issued I shell not employ any person In any manner u as to RAN CHECK became subject to the Workers Compensation w Lighting Fixtures First 20 APPLICANT Total No Additional✓� ADDRESS NOTICE TO APPLICANT a alter me • Cer nsof 15 OR 20A 120V BRANCH CIRCWT9 CITY 7r No y Exemption you should become subject to thehe er WorkCompensation I TO IO INCLUSIVE EACH provisions of the Labor Code you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERYrfAPPLICANT Provisions or this permit shall be deemed revoked 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A 200V TO Zr2V LIGHTING EACH dy-� (commencing with Section 7000)of Division 3 of the Business and CITY n Tal No 'a O V Prolusions Code and my Ikarus 16 In lull force and effect RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR v M.9- nn./'�rf Poser Apparatus 8 Apparatus Large AppBerce, REG NUMBER Llcens Numk Cl ber_�Leo B- L 1 V Cqo Size 3 Type HP KW KVA or KVAR 4aiRICT NO ,(' p PROCES SED BY CDNT/PENtAL Up to3lna y d0 W Contractor �2 CDR I If rr a q-13- 92 Md Over 3 to 10 a �ry Over 10 to 50 Incl DATE ❑ I am exempt under Sec Over SO to 100 Ind VALIDATION ? B aP C for this reason Over,100 aur Services Swbd MCC a Psnelboerds O 0(� Under 300 V Signature P il! 201 1000 Amp Under 300 V ❑ Exemption for Reg Mehl Elect Over 1000 Amp w Over 800 V SINGLE FAMILY Temp Power Pde a Appurtenances HOME OWNER BUILDER DECLARATION Sign with Erle Branch Circuit Ar.C1 .v I hereby affirm that I am exempt from the Contractor a License Lew _ for the fdlowing reason(Section 7031 5 Business and Prolusions Additional Sign Branch Circular, --3D7 i, ,�, Code) ❑ Mist: Condubs a Canductoe i LjCrr�' I as miner of the property will do the work and the structure Is not Intended or offered for sale(Section 7004 Busirleu Other(See Complete Fee Schedule)_ , %TL �,!¢ e 35 and Ptofeskns Cade) C E(l, 94. CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending egaroy for the _I�Fr,3 ,[I� Performance of the work for which this permit Is issued(Sec 3097 PERMIT FEE (Sub-Total) Ov C) Lervfer•Nemo IACHECKING PN FEE CCU-1-011 4/1-Y02 PERMIT ISSUING FEE a S i,Oi4 1 AI'I a J Lender a Address TOTAL FEE . 3 I carufy that I have read this application and Hate that the above information Is correct 1 agree to comply with all County wdinancu and State IBM regulating Electrical wiring and hereby authorize representative of this County to enter upon the above mentioned property for Ins rP s BEE REVERSE FOR EXPLANATORY LANGUAGE ,/ T y-l3TE 92