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Home My Public Portal About5760 PRIMROSE AVE_Electrical__ WORKERS'C06PE.NSATION DECLARATION f 76A663 10,81 APPLICATION FOR ELECTRICAL PERMIT I lierely.affirm )p��t I lbave a certificate of consent to self CE-8066 i0sure, or a c�►Yifif'ate.�#�`A'a-ters'Compensation Insurance, •COUNTY OF LOS ANGELES i BUILDING AND.SAFETY or a sertifipy there (Sec. 3800, Lab. C:) P9— POKY No. ComBRY� FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnis�`ie'&: -.. _ New Residential Bldgs. &Pools EACH NO. FEE ADDRESS �j D i /17°,�l>�� 'Certified copy is filed with the countyboilzling $ _ $ LOCALITY i y, Sq. tion department. -•-,� .�` Multi-family Sq. Ft. N&OREST $l 4AI -V- Residential Swimming Pools CROSS ST. /� OWNER OR Date Applicant • ..FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL. COMPENSATION INSURANCE Outlets:.Rec Light Sw._ ADDRESS Ifr This section need'not be com leted if the work involved b First.20 ( P 9 Total No. �� Additional CITY CG Tel. No. the permit is For one hundred dollars($100)or less.) ' I certify that in the performance of the work for which this i` , PLAN CHECK permi I is issued,I shall not employ any person in any manner APPLIi ANT so as.to become subject to the.Workers' mpe tion Laws. Lighting Fixtures First 20 ADDRESS _ Additional 'NIN S_13� Total No. a CITY Date npplicc Fixed Appliances Not Over 1 HP PERMIT NOTICE' TO APPLICANT: If, r ma ring this Certificate o APPLICANT Exemption, you should come subject to the Work ' Range_ Heater_D.W. —y- Compensation provisions of the Labor Code, you must forthm Oven —Dryer J_W.M:J_ ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan _Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm thpt 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 DISTRICT NO. PROCESSED BY and Professions Code,and my license is in.full force and effect.-, Power Apparatus&.Large Appliances Size&Type HP, KW, KVA, or KVAR- t U xv O License Number Lic. Class Up to 1 Incl. FINAL Contractor Date 1 Over'1 to 10 Incl. DATE J 09 VALIDA ON E] Over 10 to 50 Incl. FINAL V I am exempt,under Sec. Over 50 to 100 Inc. BY W d. BAP.C. for this reason. Over 1'00 Z Date: Services, Swbd.,MCC&Ponelboards , 0 -200 Amp. Under 600 V Signature 201 :1000 Amp: Undey600 V Over 1000 Amp: or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY 7,016 A HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances Sign with One Branch Circuit # o o 0 0.02 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 703'1.5, Business and '� o o 1 7 5.0 Pr fessions Code.): Misc. Conduits&Conductors' o 0 0 1 7.5 0 5 I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ® OS 1 2 a 8 7 7044,'Business 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 PERMIT FEE (Sub-Total) � (Sec. 3097, Civ. C.). � PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE SZ Lender's Address -70 1 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 authorizer resentatives of this County to enter upon the abov ent' a pro ert r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igna u: of Permittee a Date ? JWORKF.F{.'iCOAAPENSATIONDECARATION 76-883 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, CE-eoeG Qr a certificate of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.,C-) 1. w . Poiigy No. Company FOR APPLICANT TO FILL IN JOB ; ADDRESS_ 1•Certified copy is hereby furnished. New Residential Bldgs.&Pools $EACH NO. $ FEE LOCALITY 1:1Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ i NEAREST department. Multi-family Sq.Ft. Residential Swimming Pools CROSS O Date Applicant OWNER OR t . FIRM NAME%. $ CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE' Outlets:Rec �Light t 2 ^r ADDRESS ` (This section need not be completed if the work involved by the First 20 ►J permit is for one hundred dollars($100)or less.) Total No�p1 Additional CITY �i� Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ APPLICANT p y any person in any manner so as to become subject to the Workers'CompensatKl?Laws. Lighting Fixtures First 20 ADDRESS r Additional Dat zl�yApplic Total No._ 6 CITY Tel.No.. Fixed Appliances Not Over 1 HP NOTI E TO AP ICANT: If, after makirig this Ce '' PERMIT i Exemption,you should become subject to the Workers'ceri5pensation Range_ Heater D.W. _ APPOCANT 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. _ LICENSED CONTRACTORS DECLARATION Hood _ Fan 4— Other_ / CI.TY Tel.Not '� I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. d , LICENS OR (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. Power Apparatus&'Large Appliances DISTRICT NO. PROCESS BY Size&Type HP,KW,KVA,or KVAR O License Number Lic.Class Up to 1 Incl. FINAL 8 Over 1 to 10 Incl. DATE ` VALIDATION Contractor Date Over 10 to 50 Incl. FINAL/ ❑ 1 am exempt under Sec. Over 50 to.100 Inc. BY W B.&P.C.for this reason Over 100 n- N Services,Swbd.,MCC.&Panelboards ® Z Date: 0-200 Amp.Under 600 V LM Signature 201 - 1000 Amp.Under 600 V ❑ - Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit � c I 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 CCoode)): Misc.Conduits&Conductors 7 40.733L7 I,as owner of the property,will do the work and the structure q �q •� is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). TOTAL 4-0.75 CONSTRUCTION LENDING AGENCY CEM 40.75 I hereby affirm that there is a construction lending agency for the by Performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) ° Civ.C.). Lender's Name PLAN CHECKING FEE Lender's Address PERMIT ISSUING FEE 3a4 I IGO01 I certify that I have read this application and state that the above TOTAL FEEaA information is gorrect.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize repreSentati of this County to ent r upon the above-mentioned property r' spection Pur s. SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature of Permittee ate , WORKERS'COMPENSATION DECLARATION CE-806G ,D,e, APPLICATION FOR ELECTRICAL PERMIT , " r�affirm that I have ve a certificate of consent to ;.If insure, "fl or a certificate of Workers' Compensation Insurance, or a certified i ,� 3 COUNTY OF LOS ANGELES BUILDING AND SAFETY cods.thereof(.Sec.3800,Lab..Ca FOR APPLICANT TO FILL IN JOB /I policy No. Company ADDRESS �(! �// G C Certified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ❑ 1 &2-Family,S Ft. $ _ $ LOCALITY 7 " Certified copy is filed with the county building inspection y� q• NEAREST department. Multi-family Sq.Ft. CROSS ST. �fv__Ao� Date Applicant Residential Swimming Pools OWNER.OR -FIRMNAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light—Sw.— MAIL s �° �Q U ^ COMPENSATION INSURANCE (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 CITY Tel.No. PLAN I.certify that'in the performance of the work for which this permit APPLICANT CHECK is issued, I shall not employ any p rson i ,any manner so as Ao become subject to the Work .om a ss on Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. 1 Date Applican Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICA Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS GG' oe� G� provisions or this permit shall be deemed revoked. Top — FAU _ W.H. CITY e.:5-761,No..J-2 S/91 LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR REG. .� �a (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER 3 Class.l� Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY Size&Type HP,KW,KVA,or KVAR Q License Number a 3 3 -S3~��L;c.Class Up to 1 Incl. FINAL ,�y /y V f Over 1 to 10 Incl. DATE �,(� ✓(Q VALIDATION O Contra te. Over 10 to 50 Incl. (f [� ❑ FINAL 8 I am exempt under Sec. Over 50 to 100 Inc. BY LU Over 100 B.&P.C.for this reason o- Services,Swbd.,MCC&Panelboards ® Z Date: 0.-200 Amp.Under 600 V Signature ' 201 - 1000 Amp.Under 600 V El Exemption 1000 Amp.or Over 600 V Exemption for Reg.Maint:Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER.DECLARATION Sign with One Branch Circuit I.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): ❑ I,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), 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-Total) Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application od state that the above TOTAL FEE. 31of is correct.I agree to comply with all County ordinances laws regulating Electrical wiring, and hereby authorize ives of this County to enter upon the above-mentioned r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Permittee. q to