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HomeMy Public PortalAbout5615 SANTA ANITA AVE_Electrical__ wb . COMPENSATION DECLARATION 20.0019 DPW(72-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affTithatI m that have a certificate of consent to self insure, 78A863 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. �- Policy No.-19�Ci parry 7�C &i✓�� FOR APPLICANT TO FILL IN ADDRESS 0 Certified copy is hereby,furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY inift1&2-Family,Sq.Ft. — $ $ Certified copy is filed with the county building ins action — _ NEAREST department. Multi-family Sq.Ft. CRoss sT. Date�c,` 77` Applicant Residential Swimming Pools.yv�76 ASSESSOR MAP BOOK PAGE� FARCfL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.._Light Sw. FOIpM NAME 4� COMPENSATION INSURANCE First 20 MAIL �o (This section need not be completed If the work involved by the Total No. Additional ADDRESS /�O� �• Zse,cam s-s, permit is for one hundred dollars($100)or less.) I certify that in the performance of the wo is permit CITY T.I.No. is issue!�� ot emplOy�p n inany manner so as to PLAN CHECK becomehe C rs'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER'3 HP. NOT06E 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 provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances G r LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. CIN Tel.No. 3.e O (commencing with Section 7000)of Division 3 of the Business and •� o,.rP Professions Cade,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR Class. Over 50 to 100 Incl. REG.NUMBER Z d'6 p '� k•�- I?/ —/ ® Over 100 DISTRICT NO. P O ESSE0 BY U License Number 9 v Lic.Class t,. Services,Swbd.,MCC&PanelboardsI= Contractor ~Date 0-399 Amp.Under 600 V DATE 0 ❑ I am exempt uder Sec. 400-1000 Amp.Under 600 V Over 1000 Amp.or Over 600 V FINAL Over W B.&P.C.for this reason BRANCH CIRCUIT FEES BY co 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 ;: s r HOME OWNER-BUILDER DECLARATION Si n with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law 9 -2.71-+ for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ^ .03 Code): E 3��J ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors r, is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL '-16. 48 and Professions Code). ® CHE K v'6.$2 CONSTRUCTION LENDING AGENCY C irl I hereby affirm.that there is a construction lending agency for the CHARGE Performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) a Civ.C.) PLAN CHECKING FEE 1i11I1 -E (;i �! til`:'t Lender's Name PERMIT ISSUING FEE ��p 3311 1 HI I 9` ` Lender's Addfgs rjp' I certify that I have read this application and under penalty of purjury state TOTAL FEE d 0 that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize representatives of th's County to enter upon the above-mentioned property for ins act' osas. SEE REVERSE FOR EXPLANATORY LANGUAGE OOOCr 50NOUME OF PERMITTEE DATE WORKER'S COMPENSATION DECLARATION I76A6e3 DPW(12-91) /A®®�I,CATI®N FOR ELECTRICAL PERMIT ll I hereby affirm that I have a certificate of consent to self insure, b`91�s, 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.) ❑ Y r�ff`' Carry j� FOR APPLICANT TO FILL IN JOB 5[/ '7/, (!4 1` Policy No/�2010el Com an f� "1 ADDRESS ✓v 7 •���� Certified copy is hereby furnished, New Residential Bldgs.&Pools NO. EACH FEE r r. $ $ LOCALITY 7,t Y ;Z)J-p GI Z ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST f�department. 1 �L Multi-family Sq.Ft. — CROSS ST. Date"� 3/ J Applicant flP/� —(/}" _' Residential Swimming Pools ASSESSOR MAP BOOK J PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. FFIRM NAME �� ! COMPENSATION INSURANCE First 20 MAIL f (This section need not be completed if the work Involved by the Total No. Additional iADDREss 13e90 -E 41&I 9-/— "�► w©� permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY r#L,0�7171gM Tel.No308_&Zf- 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 Code, you must forthwith comply with suchPERMIT 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 provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. >_LICENSE Class d Over 50 to 100 Incl. REG.NUMBB ER 'V 43 D 6 f � Over 100 DISTRICT NO. PROCESSED BY O License Number Lic.Class 0 (�,�/ r` Services,Swbd.,MCC&Panelboards Contractor • Date 3'" 0-399 Amp.Under 600 V DATE 0 ❑ 400-1000 Amp.Under 600 V L��6—� V VALIDATION I am exempt under Sec. FINAL 6 W Over 1000 Amp.or Over 600 VIIL B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z Date: 15A,or 20A,120V,Lighting or Recept. _ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,2DA,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION : 4:•{4 a I hereby affirm that 1 am exempt from the Contractor's License Law Sign with One Branch Circuit , °F for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits -+ Code): • tiJL! C?Ilt 3 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 1 FE I is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule141 67- 65 ) t i° and Professions Code). CP ,% n CONSTRUCTION LENDING AGENCY '"r Ea °' 1 hereby affirm that there is a construction lending agency for the f:Z(=1 .y .''31 performance of the work for which this permit is issued(Sec. 3097, PERFEE (Sub-Total) oql 26Civ.C.) PLAN CHECKING FEE I j;( i {— } �•f"'_ �C'" Lender's Name // u. ,r is r PERMIT ISSUING FEE p?(p 1 Lender's Address I certify that I have read 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 regulating Electrical wiring,and hereby authorize ` representatives of this County to enter upon the above-mentioned property for insp n purposes. i SEE REVERSE FOR EXPLANATORY LANGUAGE o�. r 713i SIGNATURE OF PERMITTEE DATE i ,