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Home My Public Portal About5639 PERSIMMON AVE_Electrical__ I hereby aff4ORKER h,rnve COMPENSATION cer eate oDECLARATION LARA Oto self insure, ;69 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT or-a certifiggte•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.Cl � 1C.4 <JGl t� FOR APPLICANT TO FILL IN pODRES3 PoliNo. Company [ 3 cy j Certified copy is hereby furnished. New Residential Bldgs.&Pools NO.1 EACH FEE LOCALITY ❑ Certified co Is filed with the count building Inspection• 1 &2-Family,Sq.Ft. — $ $ PY Y 9 — NEAREST.. department. Multi-family Sq,Ft: CRoss ST. CJ{OFi�� . Date Applicant l�lA •�' Residential Swimming Pools ASSESSOR MAP BOOK I PAGE PARCEL . CERTIFICATE OF EXEMPTION FROM WORKERS' 'Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAME (This section need not be completed If the work Involved by the First 20 pDDREss permit Is for one hundred dollars($100)or less.) Total No. Additional I certify that In the performance of tfie work for which this.permit ' CITY Tel.No. W Is issued, I shall not employ any person in any manner'so as to' PIAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20' APPLICANT Total No. Additional ADDRESS Date - Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE-TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code,you must forthwith comply with such PERMIT provislbris or this permit shall be deemed revoked.. Power Apparatus&Large Appliances. APPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)of Division 3 of the Business and CITYTel.No. 23 Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE!OR Clew. �_ d Over 50 to 100 Incl. REG.NUMBER License Number Lic.Class Over 100 DISTRICT NO. PRC ED BY V ^� Services,Swbd.,MCC&Panelboards .�® Contractor Date r 0-399 Amp.Under 500 V DATE 0 ❑ I am exam under'Sec. 400-1000 Amp.Under 600 V b42z-� VALIDATION pt Over 1000•Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY 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. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances- HOME OWNER-BUILDER DECLARATIONra I hereby affirm that I am exempt from the Contractor's License Law Sign with One.Branch Circuit HCC I'o T for the following reason(Section 7031.5, Business and Professions Additional Sign:Branch Circuits 3303 :`7.MS Code): - 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors ) ❑ Is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAIL 87®65 and Professions Code). CONSTRUCTION LENDING AGENCY CHECK L? I hereby affirm that there is a construction lending agency for the CHANGE e001 performance of the work for which this permit is'issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE Lender's Name 001010-0011111 1/18/94 PERMIT ISSUING FEE alp 3534 1 Arl 9 10 Lender's Address TOTAL FEE S I certify that I have read this application and under penalty of purjury state that the above Information Is correct. I agree to comply with all County ordinancend State laws regulating Electrical wiring,and hereby authorize repress. Ives of this County to.a ter upon the above-mentioned property for in;poKrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � Y,PERM' E DATE Z reb ' WORKER'S haveCOMPENSATION DECLARATION �6A683 DPW(t2.91) APPLICATION FOR ELECTRICAL PERMIT I I herebyaffirm that I have a certificate of consent to self insure. .or a certifigate.of Worker's Compensation,Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec"./3800 L C .. i Policy NO.�r`e,s �+u"''panY=� '`��' FOR APPLICANT TO FILL IN JOB �.._ A A , ❑ ADDRESS �3 f' "Ori. Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY /+ — $ $ NEAREST Certified co is filed with the coup buildin Ins a ion 1&2 Family,Sq.Ft. departmentPY g P Multi-family Sq.Ft. oS . Date ^� Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM KERS' Outlets:Rec. Light S�v. OWNER OR COMPENSATION INSURANCE �Q �i FIRM NAME First 20 MAIL ` (This section need not be completed if the work Involved by theTotal No. Additional O ADDRESS permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CI Tel.No. -Al LW is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Cade, you must forthwith comply with such PERMIT P P Y provisions or this permit shall.be deemed revoked. Power Apparatus&Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS ig-Na ( � I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)of Division 3 of the Business and CI �jCAA Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR >_Over 50 t0 100 Incl. REG.NUMBER Cl... �� 0 (� S� r I Over 100 DISTRICT NO. P SED BY License Number `� y Lic.Classes� V Services,S Yd.�M FINAL& = _ Date I L --74 m•Under 600 V DA O F1400-1000 Amp.Under 600 V VALIDATION V I am exempt under Sec. LU Over 1000 Amp.or Over 600 V FINAL o- a B.&P.C.for this re P n1. BRANCH CIRCUIT FEES BY Cl) Date. �l 15A,or 20A,120V,Lighting or Recept. Z ( 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits r_141 Or More Branch Circuits y Exemption for Reg.Maint.EI 15A,2OA,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances jy''f''f a HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 33 -111 , ars- r c for the following reason(Section 7031:5, Business and Professions Additional Sign Branch Circuits .,av' Code): .y ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors -rriTAL 127 5 is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) el T and Professions Code). -, s_i�E rs 1 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-Total) Civ.C.) PLAN CHECKING FEE I.a�j}Il s i(�) �• �' {t Lender's Name PERMIT ISSUING FEE �(p 3`I'�t i AN i`I`+'" Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE / �5 that the above information is correct. I agree to comply with all County ordinance and State laws regulating Electrical wiring,and hereby authorize repress tives of this County to enter upon a above-mentioned property for in;r�rp_es, SEE REVERSE FOR EXPLANATORY LANGUAGE REOM,. E DATE