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Home My Public Portal About9508 PENTLAND ST_Electrical__ WORKER S'COMPENSATION DECLARATION 1768683 APPLICATION FOE CTRICAL PERMIT i CE EOBG (2 50) E I hereby effum that I have a certificate of conseril to a'alfor ,� COUNTY OF LOS ANGELES BUILDING AND SAFETY I ' insure or ace thcate of Workers'Compensation Insurance or - a certified copy[hereof(Sec 3800, Lab Cr) I ' , ' FOR APPLICANT TO'FILL IN ,JOB Policy No Company❑. - EACH NO FEE ADDRESS SV �✓I//�r�New Residential Bldgs & Pools Certified copy is hereby furnished 1 &2 Famdy,Sci Ft $ $ LOCALITY • L g p Multi family Sq Ft — NE ST Certified'copy u filed with the county building inspection CROSS ST department Residential Swimming Pools OWNER s � FIRM NAMM E Date i 'Applicants Outlets Rac Light��Sw , MAIL First 20 ADDRESS i ' ,CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY Tel No COMPENSATION INSURANCE + _ a {` PLAN CHECK APPLICANT O ('This section need not be completed if the work involved O d ` U Lighting Fixtures First 20 by the laermttfs for one hundred dollars (5100) or Tess) i, ADDRESS i v Total No 2 Additional � I certifv that in the performance of the work for which this CITY Tel No F- t Fixed Appliances Not Over 1 HP permit u issued 1 shell not employ any person any mannei PERMIT U W so as to become subject to the Workers Compensation Laws Range_ Heater_D W ( APPLICANT C Ovem*= Dryer_W MADDRESS N Date Applicant Top FAU _W H Z Hood Fan _Other_ CITY Tel No NOTICE TO APPLICANT If after making this Certificate of ,Disp _ Room Air Cond_ LICENSE OR Exemption you should become subject to the Workers REG NUMBER Class Compensation provisions of the Labor Code you must`fortli Power Apparatus& Large Appliances - DISTRICT NO PR BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP, KW KVA or KVAR Up to 1 Incl FINAi i JV Over 1 to 10 Incl DATE L LICENSED CONTRACTORS DECLARATION ) Over 10 to 50 Incl VALIDATION 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 Bus, Over 100 BY ness and Professions Code, and my license is in full force and /� a � ' effect Services , "O `6 - +. 0 200 Amp Under 600 V License Number Lic Class ` 201 1000 Amp Under 600 V ' Contractor Date Over 1 ODO Amp or Over 600 V ( J 0 HOME OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances I I hereby affirm that I ami exempt 'from•[he Contractor's Sign with One Branch Circuit Additional Sign Branch Circuits License Law for the following reason (Section 7031 5.Bust . 1 ness and Professions Code) I I J ' Misc Conduits&Conductors - - Tas 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) CONSTRUCTION LENDING AGENCYI r -1 3 5 4.6 A I hereby affirm that there is a construehon lending agency for the performance of the work for which this permit is PERMIT FEE - (Sub Total) t # •I• • • • 2 1 issued (Sec 3097 Civ C) , ' Lender s Name PLAN CHECKING FEE (Ona Fourth Permit Fee) 21a e 29 5 0 r Lender's Address 'PERMIT ISSUING FEE 2 Q 5 0,Q 4 1 I,certify that I have read this application and state that the TOTAL FEE 1 2 2 9-80 , 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 inspectwn purposes SEE REVERSE POR EXPLANATORY LANGUAGE 2-2t Sig azure of Permute Date • f ' ' WORKERS have a certificate of r 79Ae63 ,pia, APPLICATION FOR ELECTRICAL PERMIT ' {� 11 hereby -affirm that I have a ceriR,cate'ol consent to self Insure CEB0643LJ or a certificate of Workers Compensation Insurance or a cerafed COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec 3800 Lab C) Policy NO+ Conupeny FOR APPLICANT TO FILL IN JOB - `�.�y ❑ Certified copy Is hereby furnished New Residential Brigs 8 Pods EACH NO FEE ADDRESS 151 ` Certihad'copy Is filed withrthe county building Inspection 1 8 2-Family Sq Ft $ — $ LOCALITY L❑' tlepertment Multi-tamely SQ Ft — NEARESTCROSS ST .h 1Apdcant Residential SwsmOWNER OR m,ng Pods '` + I ` R F IRM Date i ' ywa CERTIFICATE OF EXEMPTION FROM WORKERS t Outlets Rec?Light L Sw 4� w I , Q c 4 COMPENSATION INSURANCE PDDRESS-1 G. L.O�S� /(. (This section need not be completed H'the work Involved by the First 20 , permit Is for one hundred dollars($100)or less) Total No Additional + CITY V� �Zz Tel No '[�(p. 4 -0 I certify that In the performers of the work for which [his permit ' + PLAN CHECK tis Issued Irshall not employ any person In any manner so as to APPIICAnfT - become subject to the Workers Compens tiL.,�,pwg a 9ut0.>L Lighting Fixtures }�I First 20, ADDRESS JIBS I ��Il�nff++ Total No �� CITV� Tel No 2 Date Lf-9_��;{ Appl¢ant �r NOTICE TO APPLICANT If after making this Certificate of Fixed Appllerq/s Not Over 1 HP r ' PERMIT Exemption you should become subject to the Workers Compensatian Range—/ Heater W APPLIC1s1T ' provisions of the Labor,Code you must forthwith comply,with such Oven Dryer M ADDRESS _ F o V provisions or this permit shell be deemed revoked Top FAU W H LICENSED CONTRACTORS DECLARATION Hood Fan Ther— CITY r�Y - -�" Tel No hemby affirm that I am licensed under provisions of Chapter B 90 LICENSE OR, (commencing with Section 7000) of Dr,mon 3 of the Businessland Dysp Roam Nr Coed REG NUMBER � 'A"f Class Professions Code and my license is m IUII force and effect Rorer Apparatus 8 Lenge Appliances gSTRIOT NO PROCESSED By See 8 Type HP KW KVA or KVAR (J ' License Number " L,c Class _ " '� - ' ` lip to 1 Incl FINAL Oyer 1 to 10 Incl DA's_ M Contractor Date _ Over 10 to 50 Incl E] U I am exempt under Sec - r - _ Over 50 to 100 Inc FINAL ' FI {yJ B&PC for this reason Over 100 v PL Date Services Swbd MCC<& Panelboards Z A0- 2DO Amp Under 600 V Signature fir. 201 - 1000 Amp Under 600 V Over 1000 Amp a,Over 600 V + ❑ Exemption for Rep Malnt Elect SINGLE FAMILY Temp PowerfPde 8 Appurtenances ;19353,A_ tI _ _ HOME OWNER-BUILDER DECLARATION ' ! r + 1 c 'Sign with One Branch,ClrcuR '+ e e e°ti'e 1 hereby affirm that I am exempt from703 the Contractor r s Profes7Lew fY 2 for the ldlmwlrg reason(Section 7037 5 Business and Professore _ AddRKInaLSgn Branch Circuits . • , , Coda .I -A 1 ,7.0 0 I I as owner d the °• , Mlsc�Conduits Conductors'` Property well do the work and the structure e 00 1 7 0 0 6 Other(See Complete Fee Schedule e not intended or offered for sale (Sedco 7044 Business' L ) I and Professore Code) . r S - 040 8`-8 8 CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the ; performance of the work for which this permit Is esued(Sec 3097 PERMIT FEE ` a (Sub-Total) - • r>• 4 CN C) • - ' PLAN CHECKING FEE - - - - •- r Lenders Name n I <" r ' PERMIT ISSUING FEE' T r r Lenders Address I certify that I have read thus application and state that the above TOTAL FEE, \ _ , _ t , Informatiori Is correct I agree to comply with all County ordinances , PIN and State laws Wring regulating Electrical ring and hereby authome IDV _ / reW prrr tat!"s I County to enter upon the above-mentioned f I . I for Ins s , I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of VrIntlibe ,