The URL can be used to link to this page

Home My Public Portal About5635 PAL MAL AVE_Electrical__ WORKERS COMPENSATION DECLARATION 0-001 PW 7BA663 D (12 91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm That I have a certificate of consent to sell Insure or a cerhhcatP of Wot.ar s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF RUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 3800 Lab C) Policy NO Company FOR APPLICANT TO FILL IN JOB 1 �� •I I_. DB011letl Ce ADDRESS rr__ r ,.}P�lfi� copy Is hereby fu rmshed New Residential Bltlgs 8 PONS NO EACH FEE LOCALITY -ptln LQ C; l ❑ Certified copy Is filed with the county bulldmg Inspection 1 8 2 Family Sq Ft — $ $ department _ Multi family Sq Ft — NEAREST CROS$S ^I� Dak Date Applicant Residential Swimming Pouts r r ASSESSOR n MAP BOOK PAPE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS Outlets RedLt9ht Sw L OWNER OR COMPENSATION INSURANCE M / FIRM NAME ^ First 20 /lf/ (This section need not be completed If the work Involved by the AA�� permit Is for one hundred dollars($100)or lees) Total No Additional ADDRESS I .artily that in the per/ormance of the work for which this permit CITY �(^ 1JZ Tal No Is issued I shell not employ any person In any manner so as to too HECK became subject to the Workers Compensation Laws Lighting Fixtures First 20 b� APPLICANT Total No Additional ADDRESS Date ' Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO APPLICANT 11 after to the this C mof CITY TN Na Exemption you should become subject to the Workers Compensationwith such OTHER APPLIANCES NOT OVER 3 HP provisions of the perms Code you must forthwith comply with such PERMIT provisions or this permit shell be doomed revoked Power Apparatus 8 Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size 8 Type HP KW KVA or KVAR ADDRESS I hereby affirm that I em licensed under•provisions of Chapter B Over 3 to t0lncl (commencing with Section 7000) of Division 3 of the Business and CITY TO No Professions Code and my license Is In full force and effect Over 10 to 50Ind LICENSE CI,.• Over 50 to 100 Incl d REO NUMBER License Number Lc Class Over 100 DISTRICT NO PROLES BY Q Serylces Swbd MCC 8 Penelboards Contractor Date 0 399 Amp Under 600 V FINDATE Q ❑ I am exempt under Sec 400 11X)0 Amp Under 600V O'/8 �9 VALIDATION V Over 1000 Amp or Over 600 V FINAL W B 8P C for this reason BRANCH CIRCUIT FEES er � 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 1 S 20A 208V To 277V LightingBr Orwlm SINGLE FAMILY Temp Prover Pole 8 Appurtenances; i HOME OWNER BUILDER DECLARATION Sign vnih One Branch Circuit tn t 1 hereby affirm that I am exempt from the Contractors License Law 3303 60.40 for the following reason (Section 7031 5 Business and Professions AddNanal Sign Branch Circuits Code) 1 ITEMS LR=1 I as owner of the property will do the work and the structure Mwc Conduits 8 Conductors T/yT/J 606(41"7 Is not Intended or offered logy sale (Section 7044 Business Other(See Complete Fee Schedule) h4f�IL+L�Ix U.YYlV1 and Professions Code) CONSTRUCTION LENDING AGENCY _ CKA%E aJLz I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is Issued (Sec 3087 PERMIT FEE (Sub Total) 3 M-13M1 9/ 6/95 Ov C) PLAN CHECKING FEE Lender a Name 2155 1 fel 8-15 PERMIT ISSUING FEE Q Lender Address / I comfy that I have read this application and under penalty of purjury stale TOTAL FEE (p Q 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 the above mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE .SID RE P RMITTEE DATE WORKERS COMPENSATION DECLARATION ` CE-8063 12 801 APPLICATION FOR ELECTRICAL PERMIT {� 76806LI 1 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 - T ` w a certiffieddW,lctopywt ereo�Sec 3800, Lab C)}� .1 / , Pol+cy No' _IT�b3yCompany IYP-ems' u - FOR APPLICANT TO FILL IN ,1pg New Residential Bldgs & Pools EACH NO FEE ADDRESS Certified copy is hereby furnished 1 & 2 Famdy,Sq Ft $ — $ LOCALITY e G CertiOed co '� Multi family Sq Ft — NEAREST copy is filed with the county budding Inspection CROSS ST z depart t Residential Swimming Pools OWNER OR f ' pp ' FIRM NAME Ewa 711 Date �' s7 gpApplicant1`//s��s�C to ?L £ oTCr(✓ Outlets Rec,SL Light,_ Sw Z t MAIL Fir /20 iA ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS Total No AdditionalCITY T o COMPENSATION INSURANCE PLAN CHECK d (This section need not be completedIf the work Involved el D APPLICANT O � by the perms[ is for one hundreded d dollars (5100) or less) Lighbn Fixtures First 20 Additional ADDRESS U 2 Total No 1 certify that in the performance of the work for which this CITU Tel No U permit us Issued I shall not employ any person in any manner Fixed App hences Not Over 1 HP - PERMIT l'- U ��// so as to become subject to the Workers Compensation Laws Range_ Heater_D W _ APPLICANT 41-C ll ilQ L-t+f G l,L W Oven _ Dryer_W M _ ADORE a f�SS (ZZ �J pit � ' Date Applicant Top _ FAU —WH,— CITY I/Q Al No �-7 5- Z Hood _ Fan t _Other_ C NOTICE TO APPLICANT If after making this Certificate of Dlsp _ Room Air Cond_ LICENSE OR Exemption you should become subject to the Workers REG NUMBER 50947 Class UO Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCE SED BY- with comply with such provisions or this permit shell be SS deemed revoked Size&Type HP KW-KVA-or KVAR S ` ` r ' Up to 1 Incl ` FINAL Over 1 to 101ncl LICENSED CONTRACTORS DECLARATION DATE ✓ �/ _ 1�� VALIDATION " Over 10 to 50 Incl 0 0 FINAL 1 hereby affirm that I am licensed under provisions ns of ChapLLr Over 50 to 100 Inc 9 (commencing with Section d my is Division 3 ll the Bust Over 100 ness and Professions Code and my license Is m full force,nnd effect I Services t ' License Num6`e11L�0Q6Ltc Class 6-10 10200 Amp Under 600V qv`A Ufa LLf }' 201 1000 Amp Under r 0 V Contractor/�M•�-f+fr Z ffe(e 17,�J at 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 Sign with One Branch Circuit License Law for the following reason (Section 7031 5 Bust Additional Sign Branch Pircuits ness and Professions Code) I t I Misc Conduits&Conductors ;02370A E-1 'I as owner of the property will do the work and the Other (See Complete Fee Schedule)— i structure Is not intended or offered for sale (Section # • • • '2 7044, Business and Professions Code) I ' CONSTRUCTION LLNDING AGLNCY 43 10 1 hereby affirm that there is,a constrm.tion lending agency, for the performance of the work for which this permit Is PERMIT FEE (Sub Total) `3' 1� 4 3 Q�5 issued (Sec 3097 Ctv C ) Lender s Name PLAN CHECKING FEE (One Fourth Permit Feel r X2.1 '8-81 Lender s Address PERMIT ISSUING FEE 1 )V I ' l , 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 z t ) ordinances and State laws regulating Electrical wiring and hereby authorize representatives of this County to enter upon " •v the have men[toned roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 9 9 ( Signatuf of Permittee , Date ' t