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Home My Public Portal About9005 PENTLAND ST_Electrical__ WORKERS CI have COMPENSATIONDECLARATION of corse `"19oRvvez APPLICATION FOR ELECTRICAL PERMIT • rane1 O affirm that I have a certificate of consent to self +cr eoe� sure ora certificate at Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS or a gertifi t'!opJ tthdreof (Sec 3800, � b C ) t Policy No�eompony ✓ FOR APPLICANT TO FILL IN JOB �/T FiCertified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS W E — $ LOCALITY o nded copy is fled with the county building mspec- 1 8 2 Family Sq Ft a — /Sf'tion deportment Multi-family Sq Ft - -7-i�— r NEAREST �� atiet Residential Swimming Pools s t CROSS ST D DateApphmnt OWNER O t FIRM NAME 11 nJ;7W*r'J1'O'J1' I CERTIFICATE OF EXEMPTION FROM ORKERS Outlets Rec—Light_Sw_ MAIL COMPENSATION INSURANCE First 20 ADDRESS /0 (This section need not be completed if the work Involved by Total No Additional CITY C A � Tel No the permit Is for one hundred dollars ($100)or less ) PLAN CHECK I certify that in the performance of the work for which this PLANCHET 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 Additional Data Applicant Total No CITY — Tel No Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If, after makingthis Certificate of e Exemption you should become subject to the Workers Range— Heater—DW i APPLICPLICATION /G p L G Compensation provisions of the Labor Code you most forth Oven _ Dryer —W M _ ADDRESS if IF 0 d with comply with such provisions or this permit shall be Top — FAU —W H deemed revoked Hood — Fan —Other— CITY Gl71ry0 /�/V Tel No ,�fQ33 LICENSED CONTRACTORS DECLARATION LICENSE OR j'' Disp Room Air Cond REG NUMBER J CClass ,(V, I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO`rte PROCESSE d ,ond Professions Code, and my license is in full force and effect J /J 2 Size 8 Type HP KW KVA, or KVAR �`� 0 Liic�ennsse�Nu mJ�r "�JLic Class C-/0 Up to 1 Incl :IF INAL U Ielu f`0 wi CL��/4'-Date' Over I to 10 Ind ATE Q Contract Date' VALIDATION ❑ Over 10 to 50 Incl INAL LU I am exempt under Sec Over 50 to 100 Inc V W B 8P C for this reason Over 100 / d Services Swbd MCC 8 Ponelboords at Z x 0 200 Amp Under 600V Signature 201 1000 Amp Under 600 V v Oser 1000 Amp or Over 6W V O -Exemption for Reg-Moint-Elect- SINGLE FAMILY Temp Power Pole 6 Appurtenances HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits Professions Code) I as owner the property will o the work and the 05 Q 1 A structure is nott for Misc Conduits 8 Conductors X11 intended or offered for sale(Section 7044 Other (See Complete fee Schedule)_ Business and Professions Code) ` # e e • e e 2 CONSTRUCTION LENDING AGENCY ') • 211 ail 6 1 hereby affirm that there is a construction lending agency for2'� a 6 O e e s the performance of the work for which this permit is issued PERMIT FEE (Sub Total) (Sec 3097 Civ C ) Oa23-a8v ' PLAN CHECKING FEE Lender s Name PERMIT ISSUING FEE Lender s Address 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 ordinances and State laws regulating Electrical wiring and hereby authorize representatives of this County to enter upon the ove mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Sigir of Permdt Date ®s • WD0RER5 COMPENSATION DECLARATION '• - 7eAa010/81 CE eDBG APPLICATION FOR ELECTRICAL PERMIT- �-•� I fler%y affirm that I have a cerbhcate of consent to self insure, , .` or a certificate of Workers, Compensation Insurance or a certified ` 'COUNTYsOF LOS ANGELES - ' BUILDING AND SAFETY I'LJII copy thereof(Sec 3800 Lab C) ` - ' Y Policy No - Company 1 �' FOB APPLICANT TO FILL IN .IOB� + ❑ Certifled,copy,is hereby furnished EACH NO FEE ADDRESS - by P, ,, „ e , , New Resitlenbal BMgs & Pools • E] Certifiedcopy is filed with the county bulldog inspactron 1 8'2-Family Sq Ft -� department I Multi-family Sq Ft . =E1 SS ST ,S M 47 n D V • !Date + 3• • I - cant + Residenhel Swimming PoolsI I L,, _+� t,^••i `• � OWNER r FIRM ONAME Qr w MALCERTIFICATE OF EXEMPTION FROM.WORKERS ISL! ' Outlets Rec— ht _SwCOMPENSATION INSURANCE D om• - t r + i ADDRESSV rf iv _ (This sectlon need not be,completed H the work Imolved by the . First 20 ., Permit Is for one hundred dollars ($100)or less) , I Total No Additional• CRV C r Imertifthat,in'the performance of the work for which this , PLnry CHECK Y Parmitr -, 4-rv^-. y +%,• APPUCANT .F t is+issued I shall not employ any person in any manner so as to 1, .d + '- become subject kers tion Laws Lghti,ngta Fixtures Addison ADDRESS' Tote)No Additional CITY Tel No Date Applicant Fixed,Applianees Not Over 1 HP NOTICE,,TO APPLICANT If after' making this Cemficete of y ! , I'ERMrr + r 1 ,Exemption you should become subject to the Workers Compensation Range_ Heater_ 9W y _' r��NT _ ^ _ piovlsarns of the Labor Coda you must forthwith cornply oath such Oven _ Ryer _ W M t ,r ' ADDRESS r provu,ims'W this permit shall be deemed revoked r Tap — FAU _ WH _ _ t ,b• a LICENSED CONTRACTORS DECLARATION i Hood — Fenl Other_ CITY Tel No ' I hereby affirm that'I am ltca s d under provisions of-Chapter 9 - Dtsp•— Room Air Cord ��e _ _ LICENSE OR ' mG •,, Claw (CAmenng with Sectiolo Section 7000)of Drvlsn 3 of the Buslness'and REG NUMBER Professions Code and my license is In full force antl effect _ Power Apparatus&Large Applonces r UsTritCT NO PROCESSED BY. �L7 Y7 S¢e 8 Type HP KW KVA w KVAR ' License,Number�`_� (- Lx, Class UP[0 1 Incl ~ ` r` FINAL Over Ito 10 incl DATE /� _/�{ Q - VALIDATION, 0 Q Contract or Date ` Over 10 to 50[Fri FI e ❑ I am exempt under Sec '., Over 50 to 100 Inc B B&PC for the reason Over 100 211 N " r � DateServices Swbd MCC 8 Panelboards r• , Z 0- 200 Amp Under 600 V Signature201 - 1000 Amp Under 600 V ^• Y t ,�'QO 3 7 A ._,,,eC❑ ••. •" Over 1000 Amp oryOv 600 V , - „ _ _ ..__ _ E_emjetpn l0r Reg Maint Elect _ _p _ SINGLE FAMILY' a - TJ Temp Power Pofe& Appurtenances __. _ r + HOME OWNER-BUILDER DECLARATIONSign with One Branch Circuit •A - ` " I • • 2 5 Q ' s ,1 y_ I Hereby affirm that I err! exempt from the Contractors License Lew 'f L � ' e for the folbwmg reason(Section 7031 5 Business and Professions Addaronal Sign Branch Cicurts� . 1 a a m I . ,• a 2 5 5 0 v Code) Misc,Canderts& Conductors: 0 6 2 9 e 8 8 • ❑ f as owner of the propertye will do the work and the structure f. ' - , + F, is not intended,or offered for sale (Section 7044 eBusu ass A, 0tfler (See Complete Fee Schedule) and Pmfessrons Code) , _ _ __ _ , ' ` "�1' '" • , - „ 1 CONSTRUCTION LENDING AGENCY I hereby affirm thattthere is a construction Lending agency for the performance of the work for which this permit is issued(Sec 3097 PERMIT FEE ' '(Sub-T.'ha) `+' • . ' - •'4 ` Cry C) PLAN CHECKING FEE- Lenders Name ! D • t;' , 1 ' PERMIT ISSUING FEE Lenders Address 4 �• -� 1 + ' , I certdy that I have read this applK:atxm and state that the shove TOTAL FEE information is correct 1 agree to comply with all County ordinances and,State Laws regulating Electrical winng and hereby authorize ' re sentatives of this County to enter upon the above-m entpned ' r r •,` , - -- a W sea CC)� -SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee] Date