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Home My Public Portal About4955 PERSIMMON AVE_Electrical__ 7 I hereWORKERS'COMPENSATION DECLARATION 76A683 10/81 affirm that i ILaye a certificate of consent to self insure, CE-806G APPLICATION FOR ELECTRICAL PERMIT or"a c�ir�cafe,�,5f Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy h reof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB [:] Certified copy is hereby furnished. EACH NO. FEE ADDRESS 4955 Pers i m moY1 Av New Residential Bldgs.&Pools ❑ 1 &2-Family,Sq.Ft. $ — $ LOCALITY -rerr4 le C 1 Certified copy is filed with the county building inspection _ department. Multi-family Sq.Ft. NOES Gr Residential Swimming Pools CROSS ST. t Date Applicant n FIRMER OR NAME W 1/I!x'71 tJ � lin 1� CERTIFICATE OF EXEMPTION FROM WORKERS' Z � MNL A n M J C J COMPENSATION INSURANCE Outlets:Rec—Light_t 2 _ !_ S(ADDRESS 4 G Cjy 1 (l (This section need not be completed if the work Involved by the First 20 Y L�� permit is for one hundred dollars($100)or less.) Total No. Additional CITY CK Tel.No. I certify that in the performance of the work for which this.permit PLAN CHECK is issued, I shall not employ any person in any manner so as to APPUCANT �21IN1• become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Date ? Applica Total NO. Additional CITY ' Tel.No. —J NOTICE TO APPLICANT: If, ma king this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become su ect to the Workers'Compensation Range_ Heater D.W. _ APPU�T provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU W.H. _ CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ , I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Com• Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROLE D BY _ Size&Type HP,KW,KVA,or KVAR r Gt , License Number Lic.Class Up to 1 Incl. FINAL 71 Over 1 to 10 Incl. DATE 7 Contractor Date �� VALIDATION ❑ Over 10 to 50 Incl. FI I am exempt under Sec. Over 50 to 100 Inc. BY tyl BAP.C.for this reason Over 100. 0. 22 8 5 Q 3 A 0. Services,Swbd.,MCC&Parlelboards , Z Date: 0-200 Amp.Under 600 V # 0 000 o2 Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect Over 1000 Amp.or Over 600 V l o o 16.50 SINGLE FAMILY Temp.Power Pole&Appurtenances o 0 0 1650' HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 203-87 1 hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits for the following reason(Section 7031.5,Business and Professions Code): ❑ Misc.Conduits&Conductors I,/as owner of the property,will do the work and the structure' is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ ► and Professions Code). CONSTRUCTION LENDING AGENCY 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- 1) Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE V Lender's Address ,..L I certify that I have read this application and state that the above TOTAL FEE 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 r2 k3 f i Signature of Permitte Da e M , . p vItORKERS'COMPENSATION DECLARATION 7"663 DPW 3187 APPLICATION FOR ELECTRICAL PERMIT O I hereby offitmthat I hgve a certificate of consent to self C�W `�° insole, or a certific'bte of W6rkers'-Compensmtion lnsrurance„ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS -or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ,}� Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS J J 9 G+' b LOCALITY El Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ _ $ tion department. Multi-family Sq. Ft. NEAREST CROSS WN RSOR �, a�9� 4v~' Date Applicant Residential Swimming Pools O / FIRM NAME � �• �9 I 6 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Z�Li ht �L Sw.L MAIL ;'r- 7 ; g ADDRESS 7 i Yr/tT 4 COMPENSATION INSURANCE �r� First 20 � � Z'" / � (This section need not be completed if the work involved by Total No.`� e) Additional G a CITY C -1 mu. L-t f4 Tel. No. the permit is for one hundred dollars($100)or less.) IF PLAN CHECK I certify that in the performance of the work for which this APPLICANT Z"t,t47& permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. 16 Additional �— � Total No. CITY Tel. No. Date Applicant ,/ Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall beTop — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR — I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO, P E ED BY a and Professions Code,and my license is in full force and effect. Size&Type HP, KW, KVA, or KVAR v U License Number Lic. Class Up to 1 Incl.rut. A/C FINALkyr/�s-� Over 1 to 10 Incl. DATE le�/ ! C.� VALIDATION cc Contractor Date Over 10 to 50 Incl. U FINAL IJ I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 ` d Services, Swbd., MCC&Panelboards �� Z® CODate: 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. r L4 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power ole 8 Appurtenana nces I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ACC 1°0 Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ProfN-Inessions Code): 011Zth Jd I, as owner of the property, will do the work and the Misc. Conduits&Conductors 1 ITEN3 structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ;rIT � o � Business and Professions Code). CONSTRUCTION LENDING AGENCY CRECK 112)a 4 I hereby affirm that there is a construction lending agency for (' aui J1_ the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). ��,� PLAN CHECKING FEE PERMIT ISSUING FEE 13 Lender's Name Lender's Address 7923 1 AS, 90•_5 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 ab ve-me i7,7-z�_ prrtyfor inspection purposes. 5, * I i+� J,/eSEE REVERSE FOR EXPLANATORY LANGUAGE Si(g//n/acture of Permitfee Date WORKERS'COMPENSATION DECLARATION~ C _8o8G 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure,. or a certificate o(,.,Worksrs' Compensation Insurance, o�'a certifi&tf - BOUNTY OF LOS ANGELES BUILDING AND SAFETY oopythereof 48ec.3800,.Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. EACH NO. FEE ADDRESS ,qq-0 New Residential Bldgs.&Poo Elv.• — Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $. — $ LOCALITY e department. Multi-family Sq:Ft. NEAREST J° 3L. CROSS G/ Date Applicant, Residential Swimming Pools OWNER OR '� ` /' FIRM:NAME J o nd� /Y3 CERTIFICATE.OF EXEMPTION FROM WORKERS' A MAIL COMPENSATION INSURANCE Outlets:Rec Light—Sw. ADDRESS �� !dC/L �� (This section need not be completed If the work involved by the //�� Additional 20 permit Is for one hundred dollars($100)or less.) Total No,i.� Additional CITY /2001A Tel.No.4L/SZ9oa I certify that in the performance.of the work for which this permit APPLICANT "S&M is issued, I shall,not employ any person in any manner so as to become. u ect to he Workers'.Comp ati Laws. Lighting Fixtures First 20 ADDRESS � /0 Additional • Total No.. CITY, •"- • Tel'.'No. Date IC Applican NOTI E Tor APPLICANT: If, after maFixed Appliances Not Over 1 HPking this Certificate of PERMIT Exemption,you sh..ould become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven Dryer_ W.M._ ADDRESS provisions or this permit shall.be deemed revoked. Top FAU _ W.H. _ CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_ I hereby affirm that I am.licensed under provisio s of'Chapter 9. LICENSE OR R, Disp.: - Room Air Cond. REG:NUMBER, Class. (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT N'O� PROCTA Size&.Type HP,KW,KVA,or KVAR v, 1 License Number -Lic.Class Up to 1.Incl.. FINAL- Over 1 to 10 Incl. DATE I 60, VALIDATION Contractor Date Over 10 to 50 Incl. FINAL 0 I am.exempt under Sec. Over 50 to 1.00 Inc. BY ' Over 100 Q: BAP.C.for this reason N Services,Swbd.,MCC&Panelboatds R Date: 0-200 Amp.Under 600 V Signature 201 -'1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600.V_ Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT Aa I hereby affirm that I am exempt from the Contractor's License Law r for Code)following•reasori(Section 7031.5,Business and ProfessionAdditional Sign Branch Circuits s •3307 , 45a40 Misc.Conduits&Conductors 1 ITEMS JG^J I,as owner of the property;will dothe work and the Busin ss Other(See Complete Fee Schedule) _ is not intended or offered for sale (Section 2044:Business and Professions Code). pop. TOTAL 45 o 40 CONSTRUCTION LENDING AGENCY CHECK 455.REI I hereby affirm that there is A.construction lending agency for the CHANGE - ,.00 performance•of the work.for which this permit•is issued(Sec.3097, PERMIT FEE (Sub=Total): Civ,C:), PLAN CHECKING FEE Lender's Name 0000-00014'/23/90 PERMIT ISSUING FEE 00 0256 1 AMIOD-20 Lender's Address I certify that I have.read this application and state that the above TOTAL FEE information is correct.I agree,to comply y4th.all.County ordinances. and State laws regulating Electrical wiring, and hereby authorize representatives of this Countyy to enter upon the above-mentioned property for lhispe Pon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ate