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Home My Public Portal About5118 ROSEVALE DR_Electrical__ WORKERS COMPENSATION DECLARATION ,EAees ,D,a, APPLICATION FOR ELECTRICAL PERMIT {� I hereby etforni that I have a cerMucate ofcanserrt to Self InsureGEea6G L J or a oertiflcafe of Workers Compensation Insuremce or a cerided COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(sec SOO Lab C) Policy oil-x) Cd FOR APPLICANT LL IN JOB Lv-G;tf*d copy,a hereby furnished EACH NO FE ADDRESS � � O G New Residential Bldgs dwr ❑ Certified copy m filed with the county building mspectwn 1 8 2-Fam1ly Sq Ft $ — S LOCALITY ,e, C. tepartment Multi-family Sq Ft NEAREST O ic r r Date Apples Residential Swimming Pools Ov1NER OR FP1M NAME 1 CERTIFICATE OF EXEMPTION FROM WORKERS Cutlets Rec—Light — Sw — MAL COMPENSATION INSURANCE ADDRESS (This eectlon need not be completed If the work involved by thio Fust 20 CRY Tel No Permit Is for one hundred do lem($100)or bee) Total No Additional I certify that in the performance of the work for which thio permit PLAN CHECK s armed I shell not employ any person in any manner sc as to APPLICANT become subject to the Workere Compensation Laws Lighting Fixtures First 20 ADDRESS Addition Date Applicant Total No CITU Tel No NOTICE TO APPLICANT If after making this Certificate Of Fixed Appliances Not Over t HP PFIiMr Exemption You should become subject to the Workers Compensation Renege_ Heater_ DW _ APPLICANT 40 �- provseos of the Labor Coda you must forthwith tompty with each Oven _ Dryw _ W M _ ADDRESS 1-2%:ZLOU, prowvos or this permit Shall be deemed ravoked Top — FAU _ WH LICENSED CONTRACTORS DECLARATION, Flood — Fen _ Oder_ CITY tY Tel N.?!If Illi I hereby affirm that I am licenser] under provuaOs of Chapter 9 Disp — Room Air Cord LICENSE OR (commencing with SGdm 7000) of Dirvsion 3 of the Business and REG NUABER 7 7 C Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances DISTRICT NO PROCE Z(gY 11 Size d Type HP,KW KVA o KVAR �. v IJcense Number. 5 Luc Claes U �� ,,,, LID to 1 Incl FINAL Contractor INCL/im o10' — Date Ovar Ito 10 Inot DATE vam O Over 10 to 501mcl❑ FINAL I em exempt under Sec Over 50 to 100 Inc FIr3 BBPC for the reason Over 100 '-Azzd N Date Services Swbd MCC 8 Panelboards Z 0-200 Amp Under 600 V Signature- 201 - 1000 Amp Under 800 V ❑ Exemption for Rag Maim Elect Ovw 1000 Amp or Over 600 V ;16 8 6 2 AA, SINGLE FAMILY Temp Power Pole 6 Appurtenances #� •>) b S U HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I r the affirm that Sin exempt from the Contractors Proles Law Additional Sign Branch Circuits Q Q6 for the following reason(Section 7031 5 Business and Professions ()Q, / Code) ElMsc Conduits a Conductors a I es owner d the property wet vv the ork and the structure Other(See Complete Fee Schedule) not intendedintendedw offered tux sale e (Batten 7044 Business ► and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a coratructwn larding agency for the performance of the wok for which the permit s issued(Sec 3097, PERMIT FEE (Sub-Total) Cm C) RAN CHECKING FEE Larder Name Larders certify PERMIT ISSUING FEE that I hi I tify that have reed this eppinetwn end state that the above TOTAL FEE EEmfwmwwn s c4L,Elecinical I agree to comply with all County ordinances State lawshrg vnnrg, and hereby authonze representative my to enter upon the above-mentioned orioses ., �[j_ SEE REVERSE FOR EXPLANATORY LANGUAGE ig tune or ee • [fate WpBKf,RS COMPENSATION DECLARATION 76AW 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I hove o certificate of consent to self CE 8066 mNre «,o•cerl,bcote of Worker Compensation Insurance C� OF BUILDING AND SAFETY �or a\j�(p��i(� copy thereof (Sec 3800 Lo ) are b� any FOR APPLICANTTO RLL IN JOB Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO PEE ADDRESS , 1 8 2-Foml Ft f — 3 LOCALITY lio Certified copy r filed with the county building msjset Y of non deport ant Multi family Sq Ft — NEAREST Residential Swimming Pools CROSS ST Dole 7 Applicant OWNER OR CERTIFICAT OF EXEMPTION FROM WORKERS FIRMNAMENAME COMPENSATION INSURANCE Outlets Rec_Light_Sw_ ADDRESS lid his stolon need not be completed If the vrork Involved First 20 (T Total No Additional CITY C • Tel No the permit Is For one hundred dellen(f100)or Ips) I certify that in the performance of the work for which this PLAN CHECK permit is issued, I shall not employ any person in any manner APPLICANT so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS Total No Additional Dote Applicant CITY Tel No NOTICE TO APPLICANT If after making this Ceoi6cate of Fixed Appliances Not Over 1 HP PERMIT Exemption you should become subject to the Workers, Range_ Heater_D W _ APPLICANT Compensation provisions of the Labor Code you must forth Oven _ Dryer _ W M _ ADDRESS with comply with such provisions or this permit shall be Top _ FAU _WH _ deemed revoked Hood _ Fan _Other_ CITY Tel No LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 D,sp _ Room Air Cond —_ REG NUMBER Class } (commencing with Section 7000) of Division 3 of the Business DISTRICT NO ` U and Profearons Code and my license is in full force and effect Power Apparatus 8 Large Appliances CIX p ��[[' /��ll Size 8 Type HP KW KVA or KVAR 0 License N erLic Class__ Up to 1 Inc[ FINAL O 1-2— Over 1 to 10 Ind DATE vALIDATION n (— Conect Dote i Over 10 to 50 Incl FIN W d F1 I am exempt under Sec Over 50 to IOD Inc B N B BP C for this reason Over 100 Z Dote Services Swbd , MCC 6 Pone[boards 0 200 Amp Under 600 V Signature 201 - 1000 Amp Under 600 V Or Over 600 V Exemption for Reg Maml Eject 3 6 4.1.3 A SINGLE FAMILY Temp Power Pole 8 nances HOME OWNER BUILDER DECLARATION �gn w tie Branch Circuit # s e e e e 2 1 hereby offrrm that 1 am exempt from the Connector s Ucense Additional Sign Branch Law for the following reason (Section 7031 5 Business and Circuits Professions Code) I e - 2550 Misc Conduits&Conductor • e - 25505 I as owner o the property off do the work and the Other See Complete Fee Schedule)- 1,27-87 snucture a not intended or offered for sale (Section ( P ► # 44 70Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction [ending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec 3097 C,v C ) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Len r s Address ass I ce fy that qhnareod this application and state that the TOTAL FEEabo informaorrect I agree to comply with all County aids rices a I regulating Electrical wising and here authorse motivesofthis County to anter upon th a ove meperry for inspection purposes (�/ SEE REVERSE FOR EXPLANATORY LANGUAGE Signal re of Perms ee �po/te I " /