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Home My Public Portal About5749 PRIMROSE AVE_Electrical__ �. WORKER'S COMPENSATION DECLARATION 766asr DPW(12=9.1) APPLICATION FOR ELECTRICAL PERMIT +I fiereby;•'aff)rtn that+f nave's certificate of consent to self insure, '.ora-ce"kAge"of�IMorker'a Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.O=PUBLIC WORKS BUILDING AND SAFETY DIV. , copy the Sec.3800 Lab.C.). �. Policy^.No. Company FOR APPLICANT TO FILL IN JO ` S (� 0 I• DRESS 1 G. d B�D�L S Certified copy is hereby furnished. " .NO.. New Residential Bldgs.&'Pools EACH FEE_ LOCALITY 0 Certified copy is filed With the county building inspection 1 &2.-Family,Sq.Ft. $ $ NEAREST department: _ Multl4amlly.Sq.Ft. — CROSS sT. Date. Applicant Residential Swimming Pools ASSESSOR MAP•BOOK, PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' [RESIDENTIAL ts:.Rec._Li-ht Sw. OWNER OR' COM.PE.NSATION INSURANCE 9 FIRM NAME I C First 20 _ J (Tlfis section;need`not be completed If.the work involved by the , ADDRESS I I' permit is for one hundred•dollars(6100)of less.) otal No. Additional CA4,i=1+.�8 G I certify that in the performance.of the war.k'for which this permit CIT Tel.No. 76� is issued, I shall not employ any person In any manner so as to PLAN CHECK become subject to'the Workers'Com a sation•L•aws. ing Fixtures First 20 APPLICANT Dat APPlican - i✓" LIANCES R 3 QDDRotal No.. Additional APP NOT OVE FIP.NOTI E TO APPLICANT: If, of er.making this,'Certi:ficate of CITY ES Tel.No. SExemption,.you;should become subject to,the•Workers'Com..pensation ER APPLIANCES NOT OVER 3 HP. ' proyisions of the Labor Code,you must forthwith comply with.such PERMIT provisions 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 provis'ioria of Chapter'9 Over 3 to 10 Incl. (commencing.with Section 70.00)of Division 3 of the Business and'L CITY Tel.No. ' Professions Code,and my license is in fullOver 10'.to 50 Incl. . force and effect. �- , LICEPISE.ORC - Over 50 to 100 Incl. REG.NUMBER less' Over 100 0 DISTRICT NO P Liceise Number Lic.Class V Services,Swbd.,MCC&Panelboards. Contractor' 0=399 Amp,•Under 600 V FINAL ... Date DATE. O 400-1000 Amp.Under 600 V V I.am exempt under Sec:. a Over 1000 Amp,or Over 660 V L VALIDATION •FINAL ,B.&P..C.for this reasonBRANCH CIRCUIT FEES BY Z Date: 15A,or 20A,120V,.Lighting or Recept. e _ 1 To 10 Branch Circuits Signature 11..To 40 Branch Circuits 41 Or More'Branch.Circuits Exemption�fo.t Reg.Maint,Elect. .15A,20A,208V.To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances P h •r• a. HOME OWNER-BUILDER DECLARATION AN l oa 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 3303 65.tD. Code): -MS t,as ownei.of the property,will do the work and the stpicture Misc,Conduit's&Conductors q� is not,intended or offered for sale(Section 704.4.;'Business Other(See Complete Fee Schedule) TOTAL 65 70. and Professions Code). CHECK 65.70 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:) ,I. PLAN CHECKING'FEE tf/15,96 Lender's Name PERMIT ISSUING FEE f 026? 1 `(!jai 9e4,7.r Lender's Address D I certify that.I have read this application and under Jury state TOTAL FEE penalty of pur that t e above information is correct. I agree to comply with all County or ' a. s and State laws regulating.Electrical wiring,and hereby authorize , r- rese tatives of this.C my to enter upon.the.above-mentioned property r Ins .coon Pur SEE REVERSE FOR EXPLANATORY LANGUAGE 11 NATURE OF PERMITTEE DATE WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91). 7sasss APPLICATION FOR ELECTRICAL .PERMIT y'hereby siffinrii that,I have a certificate of consent to self insure, ora certificate"Of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sac.3800•Lab.C.) PolicyvNo.. Company FOR APPLICANT TO FILL IN If 5 pDDgESS • Certified copy is hereby furnished. sl NO. EACH FEE N'ew Residential Sidgs.&PooOLs. LOCALITY. 1 &2-Family,Sq.Ft. �,• $ nl ❑ Certified.copy is filed with,the,county building inspection NEAREST department: Multi-family Sq.Ft. CROSS_ST. Date . Applicant Residential Swimming Pools ASSESSOR -7 MAP BOOK / PA.E ell PARCEL /O CERTIFICATE OF EXEMPTION.FROM WORKERS' OWNER OR LL Outlets:Roo._Light' Sw. FIRM.NAME COMPENSATION INSURANCE First 20 (T,hls•`section,_need not be•completed if the work,lnyofyed by'the. MAIL permit is for one hundred dollars.(6400)'or less.) Total No. Additional 'ADD.gEss. ��LI.3 'CITY Tel.No.. 1 certify that:in the performance of the work for Which this permit ts',ep . 42, 'is issued, I shall not employ any person in any'manner'Bo as to - ': PLAN CHECK become subject to the Workers'Compensation.Laws. Lighting Fixtures First 20 APPLICANT i. 3 DR Total No. Additional ADESS Date 9. l Ct Applicant: ...,- RESIDENTIAL:APPLIANCES NOT OVER 3 HP: NOTICE TO APPLICANT:-If., afterm.aking'this Certificate of CITY Tel.:No: 'Exemption;you should become.subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. piovlslons of'the Labor Code; you must forthwith comply with such PERMIT Power Apparatus&Large Appliances APPLICANT L.4,V!✓ �)',lf C C.' :C. provisioris or this permit shall be deemed revoked. ��/ ff LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVA.R ADDRESS �e'fs (�(vVffrbl.. 1 e I'hereby affirnl'that•I arir licensed under:provisions of•Chapter 9. Over,3 to 10 Incl. (commencing with Section 7000)of Division 3 of the.Bus!ness and CITY- C.0ULA Tel.� No:Q&Z_cO42k Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. �. LICENSE OR 5"1 Z Li� Class. . Over 50 to 100 Incl. LCENSE O EIa L d_ G d O 'Z�. Over 100• DISTRICTWO. PROCESSED BY License Number L'ic.Class G V Services,�Swbd:,MCC&Panelboards �' Contractor-fie_ L ` "f Date ;` t L 0-399 Amp.Under 600 V i . DAA 400:1000 Amp.Under 600V ly ? El I am VA .,.,tempt under Sec.. - , ... - LIDATION Over 1000 Amp.-or-Over 600 V FINA4 y Q, .B.&P..C.for this reason y/ fn " BRANCH CIRCUIT FEES BY Date: 13 •15A,or 20A,120V,Lighting or Recept. / Z. I 1 To 10Branch,Circuits ' Signature 71 To 40 Branch Circuits 41 Or More Branch Circuits 0 Eke 'for Reg.'Mairit,;Elect. 15A,_m 208V To 277V Lighting Br,Circuits. A�'CT ag. SINGLE FAMILYp r. rr�n'� Tem Power Pole&Appurtenances 2 i> HOME OWNER-BUILDER DECLARATION I'hereby affirm that I'am exempt from the Eontractor`s License'Law Sign,with.One'Branch Circuit - ITEMS for the following,reason (Section 7031.5, Business.and Professions Additional Sign Branch Circuits Code): TOTAL 299.46 ❑ I,as oWner of th.e. ro pert .will do the work and the structure Misc.Conduits&Conductors CHECK , 24 is not.intended o Pof eyed for sale(Section 7044, Business Other(See Complete Fee Schedule). 9 = r, and Professions Code). CHANGE �C 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) a. . d LI l —J. I 1 r�� 1/93 Civ.C;) a ai t t ��3 PLAN CHECKING FEE J.53 3 Lender's Name PERMIT ISSUING FEE Q�,(pkV4 Lender's:Address I certify that I havemad this application and under penalty of purjury state TOTAL FEE . ' that the above information is correct. I agree to comply with all County ordinances and State laws regulati g:Electrical wiring„and hereby authorize representatives...f this County te. 'terzupon.the,above=mentioned property for insp i n. u s / SEE REVERSE FOR EXPLANATORY LANGUAGE sieNATU M EE DATE ,