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Home My Public Portal About5520 PERSIMMON AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76AS63 10/61 APPLICATION 1=0R ELECTRICAL PERMIT I hereby �ff'rm that I have. a certificate of consent to self insure, CE-806G ora.clerWe of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY co theXeg ^Y,�;dtfC.) PoI�yJ11v//��oJ..((// ��''��JJ JJ Company f / FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. FNewsidential Bldgs.&Pools EACH NO. FEEADDRESS 2-Family,Sq.Ft.. $ _1$ LOCALITY Cj �ertified copy is file with the county building inspection depa m t. /7 Multi-family Sq.Ft. — NEAREST CROSS ST. (j E��J- J!J Residential Swimming Pool OWNER OR Date Appl1aaht FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKER$` Outlets:R Light/ Sw.•_� MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by the First 20 permit Is for one hundred dollars($100)or less.) Total No. Additional IAN Tel.No. I.certifythat in the performance of the work for which this erm'it PLAN CHECK permit APPLICANT is issued, I shall not employ any person in any manner so as to become subject to the,Workers'Compensation Laws. Lighting FixturQss First 20 ADDRESS Total No((// Additional CITY Tel..No. I Date Applicant Fixed Appliances Not Over 1 HPPERMIT NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT r provisions of the Labor Code;you must forthwith comply with such Oven _ Dryer�: W.M. ;ADDRES provisions or this.permit shall be deemed revoked. Top _ FAU. W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan ,� Other_ CIT `� Tel.mO I hereby affirm that I am licensed under provisions of Chapter 9 ;LICENSE B 62,7Z / /e�F� c 1. Disp. — Room Air Cond. REG.NUMBER !�v Class: C/ (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 NO. PROCESSED / // � V� 0 6 (r C J Size&Type HP,KW,KVA,or KVAR i t/4 U License Number Lic.Class. `` Up.to 1 Incl.. SINAL Over 1 to'10 Incl. DATE / VALIDA 0 Contractor Date Over 10 to 50 Incl. L C/ CFS- FINAL ❑ •1 am exempt under Sec. Over 50 to 100 Inc. BY n- Over for this reason Over 100 CO) Services;Swbd.,MCC&.Panelboards , Z Date: 0-200 Amp.Undr 600 V Signature 201 - 1000 Amp.Under 6.00 V Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp:Power Pole&Appurtenances 21 2 Q 2 A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit. I hereby affirm that I am exempt from the Contractor's License Law # 0 0 0 0 0 2 for the following reason(Section 7031.5,Business and Professions .Additional Sign Branch Circuits Code): I o 7 4.0 0 Misc.Conduits&Conductors ; El 1, 0 o74,005 I,as owner of the property,.will do the work,and the structure Other(See Complete Fee Schedule) _. is not intended or offered for sale (Section 7044, Business and Professions Code). ® 1,28-88 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 1 performance of the work for which.this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the above TOTAL FEE t�� l is correct:I agree to co ly with all County ordinances.laws regulating tri firing, and hereby authorize ives i C y e er upon the above-mentioned r in ec' n Fp e m/� SEE REVERSE FOR EXPLANATORY LANGUAGE f Permittee Date WORKERS'COMPENSATIONDECLARATION CE-806G (2.80) • CE-806G APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES B D SAFETY insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) AOO, FOR APPLICANT TO FILL INSOB Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ' ADDRE - �✓ mr Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY ❑ Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection i CROSS ST / department. Residential Swimming Pools OWNER OR FIRM NAME A. L S Date Applicant Outlets: Rec.___-Light Sw. ADDRESS First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE PLAN CHECK } APPLICANT CL (This section need not be completed if the work involved Lighting Fixtures First 20 U by the permit is for one hundred dollars ($100) or less.) Additional ADDRESS Total No. I certify that in the performance of the work for which this CITY Tel No. 0 permit is issued, I shall not employ an person in an manner Fixed Appliances Not Over 1 HP P P Y Y P Y PERMIT so as to become subject to the 6d�Woorker®®s'Compensation Laws. Range_Heater D.W._ APPLICANT o��c W �./ot '° Oven _ Dryer—W.M._ ADDRESS AclC U) Dat Applicant Top _ FAU _W.H.._ CL Hood — Fan _Other_ CITYyF lfry Tel No. LcY 7 3 NOTICE TO APPLICANT: If, after making is Certifica f i Disp. _Room Air Cond._ LICENSE OR Class Exemption, you should become subject o the W s' REG.NUMBER �U Compensation provisions of the Labor Code,you in orth- Power Apparatus&Large Appliances DISTRICT NO. P S ED BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVA,or KVAR Up to 1 Incl. FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE Over 10 to 50 Incl. / ® 'CJ VALI DA ION 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 Busi- Over 700 BY ' ness and Professions Code, and my license is in full force and effect. Services 0-200 Amp.Under 600 V License Numbe• 5 0 Lic.Class &/ { A / 201-1000 Amp.Under 600 V Contractor)/�(!(-.f�[.� .—,,Date fl�� 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„Busi- Additional Sign Branch Circuits ._3021 A ness and Professions Code): Misc.Conduits&Conductors 4 o o o .a o 2 ❑ I, as owner of the property, will-do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section 2 o o i C;,„(} 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY o o „ 1 C J I hereby affirm that there is a construction lending agency G v for the performance of the work for which this permit is PERMIT FEE (Sub-Total) 1 1. 12-80 issued(Sec.3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 7 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 representat'ves of this County to enter upon the above entioned prop y nspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of rmittee Date WORKER'S COMPENSATION DECLARATION 20.0019DPW 9189 I.hereby affirm that I have a certificate of.consent to self Insure, 76ABB3 APPLICATION FOR ELECTRICAL PERMIT LLL or a certificate of Worker's Compensation Insurance,or a certified , COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) Poll No. Company FOR APPLICANT TO FILL IN ADDRF�3 �.[ ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE $ _ $ LOCALITY ❑ Certified copy is filed with the county building Inspection 1&2-Family,Sq.Ft. EST department. Multi-family Sq.Ft. CROSS-ST. y _ Date Applicant Residential Swimming Pools ASSESSOR MAP BOOKPARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' 1,70 Outlets:Rec._Light� � LLA L �O RMENAME PAGE.NAME 1' COMPENSATION INSURANCE ��1 (This section need not be completed If the-work Involved by the First 20 MAIL permit Is for one hundred dollars($100)or less:) Total.No. Additional ADDRESS ssaU L d I certify that in the performance of the work for which this permit CITY y' / G 7 Tel.No. Y is issued, I shall not employ any person in any manner so as to +1 CK G become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 1® PLAN CHECK 1 P 9 9 APPLICANT Total No. f AdditionalJALL ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you'should become subject to the Workers'Compensation 1.TO 10 INCLUSIVE EACH provisions of-the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT provisions or this permit shall be deemed revoked.. 41'OR MORE BRANCH CIRCUITS EACH APPLICANT LICENSED CONTRACTORS DECLARATION 15`OR 20A,208V'TO 277V LIGHTING EACH ADDRESS O I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. V Professions Code,and my license Is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Power Apparatus&Large Appliances REG.NUMBER Class. Size&Type HP,KW,KVA,or:KVAR DISTRICT NO. PROCESS _ . - Q License Number Lic:Class ,-►. V Up to 3 Incl. • 0 W Contractor Date Over 3 to 10 Incl. FINAL _ ❑ Over 10 to 50 Incl. DATE cc I am exempt under Sec. Over,50 to 100 Incl. J VALIDATION: Over 100 FINAL B.&P.C.for this reason BY Services,Swbd.,MCC.&Panelboards Dom' 0-200 Amp.Under 600,V Signature 201-1000 Amp..Under 600 V Q q ❑ Over 1000 Amp.or Over 600 V ✓ ~�I/ Exemption for Reg.Maint.Elect. �( 711 SINGLE FAMILY „ Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License'Law Sign with One Branch Circuit for the following,reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ~� _ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors a)-7_DQ 7 _ Is not intended or offered for sale Section 7044, Business Other See Complete Fee Schedule I I; '` and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the ', n�- performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE :< '•a.ti!k Z ” .Lender's Address TOTAL FEE I certify that I have read this application and state 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 inspects n purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE D o , SIGNATURE OF APP NT OR ADEN E