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HomeMy Public PortalAbout6229 RENO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 9 DPW 9189 APPLICATION FOR ELECTRICAL PERMIT 76A66 I hereby affirm that I have a certificate of consent to self insure, 76A663 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.) Fr Policy NO. Company FOR APPLICANT TO FILL IN JOB ❑ ADDRESS � 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. NEAREST 9 department. ` Multi-family Sq.Ft. CROSS ST. G Applicant / "[� 7. Residential Swimming Pools AS Date r' �� y`L MAP BOOK aJ©7 PAGE 4K)/ PARCEL O14P CERTIFICATE OF EXEMPTI N FROM WORKERS' Outlets:Rec._Light Sw. FlRM NAME q� , COMPENSATION INSURANCE " F First 20 MAIL (This section need not be completed if the work involved by the permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS Z I certify that in the performance of the work for which this permit CITY Tel.No. 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 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 ! �` P Y P Y APPLICANT J provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS a I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH (commencing with Section 7000)of Division 3 of the Business and CITY /t,//�,Y > Tel.No.• ! C Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR �: J Power Apparatus&Large Appliances REG.NUMBER<//(� Q Class.G License Number T Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROC SED BY Up to 3 Incl. QU. �` Over 3 to 10 Incl. Contractor �, a \ r _Date DATE DATE U, ❑ Over 10 to 50 Incl. VALIDATION I am exempt under Sec. Over 50 to 100 Incl. B.&P.C.for this reason Over 100 FINAL Services,Swbd.,MCC&Panelboards Date: -200 A Under 60000 V/pp O Signature 2�1-1081 rTd�Bt)9 V ❑ Over 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 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 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 �7 Lender's Address I ��ertify 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 purpos 7SEE REVERSE FOR EXPLANATORY LANGUAGE e2 It 24 TUBE OF APPLICANT ORA ENT DATE I .. . 5� WORKER'S COMPENSATION DECLARATION 26A�DPW 9/88 4` P PLI'NOt�T�®kl�l FOR En ECTMAL PERNT I hereby affirm that I have a certificate of consent to self Insure, I]Ci L>� tlC1N oya 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.4C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ' ADDRESS r Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE $ _ $ LOCALITY 9 Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. ST department. Multi-family Sq.Ft. CROSS SST. Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK PAGE PARCEL C RTIFI ATE OF EXEMPT FROM WORKERS' OWNER OR w COMPENSATION INSURANCE Outlets:RecA Light SW. FIRM NAME / (� ,�/- First 20 MAIL (This section need not be completed if the work Involved by the Total No.�L� Additional ADORES .z permit Is for one hundred dollars($100)or less.) I Ne I certify that in the performance of the work for which this permit CITY Tel.No. � is issued, I shall not employ any person In any manner so as toPLAN CHECK 011 become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 Q APPLICANT Total No. Additional 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 _ PERMIT .q provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT r!� � � provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >_ LICENSED CONTRACTORS DECLARATION ADDRESS „� Il I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH O (commencing with Section 7000)of Division 3 of the Business and CITY 16eA23,6E� A, Tel.No. � U Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR !Y Power Apparatus&Large Appliances REG.NUMBER Class. 0 License Number Lic.Class G Size&Type HP,KW,KVA,or KVAR DISTRICT NO. O SSED BY V Up to 3 Incl. .5-1 Vd 0- Over 3 to 10 Incl. FINAL Contractor ate Over 10 to 50 Incl. DATE 7—”Z Z F1 a exempt under Sec. Over 50 to 100 Incl. / VALIDATION B.&P.C.for this reason Over 100 BY FINAL � Services,Swbd.,MCC&Panelboards 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 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law 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 Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). 11221> 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 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}ori spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE h 41E SIG E OF PL CANT RAG NT