HomeMy Public PortalAbout5540-5542-5544 SULTANA AVE_Electrical__ WORKERS COMPENSATION DECLARATION soamvDPW vm APPLICATION FOR ELECTRICAL PERMIT O
hereby affirm car shot I have a certificate of consent r Bell OE906G insure ora certificate of Waken Compensation Insurance , COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or o certified copy thereof (Sec 3800 Lab C )
Policy NSA Lr_I NS a€ompaFOR e APPLICANT TO FILL JO
ll B
❑Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADORE 55 S 99 IVO ';LJ � 1 R N A F'IUC
❑Certified copy is filed with the county building mspec 1 8 2-Fomdy, Sq Ft $ — $ LOCALITY TCM �L C/T
tion deportment [� � / �, Multi family Sq F — NEAREST
Date 7 7d 9 Appl�rr(t Z"V/C ' pi-0 0P Residential Swimming Pools OWNER ST 0
FIRM NAME N GIZI Ca NS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE Outten Rec_Light_Sw_ MALL O N
U IYYC
(Th(Thisto
section need not be completed the sv
foh Introlved by Fant ADDRESS r- CI T IW�}(��.,the permlt Is for one,hundred dollars($100)or less ) Total No Additional- < < < OM(m Ah�C ri.0 V SIS6C7
I certify that in .he performance of the work for which this T RAN CHECK
permit is nsued, I shall not employ an - APPLICANT
pe p y y person in any manner
so as to become subjectto the Workers Compensation Lows Lighting Fixtures First 20 ADDRESS
Total No \ Additional CIN Tel No
Dote Applicant i ad Appliances Not Over 1 HP PERMIT ��
NOTICE TO APPLICANT If, after making this Certificate—
ertificate of ` APRICATIIXJ F/2 WCf� l?IC�V
Exemption, you should become subject to the Wukers Range— Heater—DW W —
Compensolion provisions of the Labor Code you must forth- Oven _ Dryer —W M _ ADDRESS 11-4 511/V
a /` pCMl-int
with comply with such provisions or this permit shall be Top — FAU —WH —
deemed revoked CIT`I� MOW TC. Te�� J I&
Hood — Fan —Other— LICENSE OR
LICENSED CONTRACTORS DECLARATION p,sp — Room Air Cond REG NUMBER '.S.� Zy Class 6
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO
and Professions Code and my license is in full face and effect - p SSED BY d
(� Size 8 Type HP, KW, KVA, or KVAR ��O p
License Number �gsav7 Lc Class `� Up to 1 Incl FINAL O
3�1r� $C(1Vletl GRpap to 2 yo rj Over 1 to 10 Incl DATE ,2--7
VALIDATION Q
❑ Over 10 to 50 Incl FINAL
I am exempt under Sec _ Over 50 to 100 Inc
BY w
B 8P C far this reason Over 100 D.
Date Services Swbd MCC 8 Ponellsonrds , Z
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
F-1 Exemption 1000 Amp or Over 600 V
Exemption for Reg Moms Elect
SINGLE FAMILY - Temp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION
hereby affirm that exempt from the Contractors ss n n with One Branch Circuit
.
Law for the following
r reason (Section 7031 5 Business andd SigAdditional Sign Branch Circuits ACC rty
Professions Code) "07
cr :r
❑ 1 as owner of the r hlnc Condmn 8 Conductor 1 I('E11'
property, will f o the work and the Other See Complete Fee Schedule .z
structure is not intended or offered for sale(Section 7014, ( P 1—
Business and Professions Code) ' TUl AL r ca=-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fa CHECK
the performance o1 the work for which this permit is issued PERMIT FEE (Sub-Total) tHANSE
(Sec 3097, Civ C ) .lid'
PLAN CHECKING FEE
Lender s Name 00011-090
PERMIT ISSUING FEE
Lender s Address , °,4
I certify that I have read this application and state that the TOTAL FEE lc" 1 n
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
th above menti d pr arty for inspection purp ses '
SEE REVERSE FOR EXPLANATORY LANGUAGE I
Signature of Permittee t� L I ms
DEC
WORKERS'COMPENSATION cafe of corse ir�'°oPwzi67 APPLICATION FOR ELECTRICAL PERMIT O
I I hereby affegi that I have a certificate of consent to self cE ea4a �
maure or a c6rtdicate of Workers Compensation Insurance, COUNTY,OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a�certified topy thereof (Sec 3800,196 ) yyO
Policy No Compo FOR APPLICANT TO RLL 111
Certified copy is hereby furnished New Residential Bldgs &Pools ADDRESS
EACH NO FEE 11
QCertified copy is filed with the county building nspec 1 8 2-Family, Sq Ft_L�-+1= s — $ LOCALITY
hon department Multi famJy Sq Ft — NEAREST
9qf Residential Swimming Pools CROSS ST
Date Applicant )
FIRM NAME L f - P,
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Re Ught_Sw_ 'WAIL _
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the swrk fn"lrad byFirst 20 i CITY Tel No _
the Permit Is for one hundred dollars(6100)or less) Total No Additional '> > -7
RAN CHECK
I certify that in he performance of the work for which this APPLICANT
permit is cawed I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
Additional
Total No CITY Tel No
Dote Appbmnt Fixed Applionces Not Over I HP PERMITAPPl1CATICMI
NOTICE TO APPLICANT If) after making this Certif tate of
Exemption, you should become subject to the Workers' Ranges Heater—DW —
Compensation provisions of the Labor Code you must forth- Oven — Dryer —W M _ ADDRESS / y 0 J;
with comply with such provisions or this permit shall be Top — FAU —W H — }
deemed revoked Hood — Fan —Other— CITY S , 0_1�-MAI Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp _ Room Air Cord REG NUMBER LL�-��"V!3 Class C--/PI hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO P17SED BY d
and Professions Code,and my license is in full force and effect
Size 8 Type HP, KW KVA or KVAR d 0
License Number ;YS be Class'�0 Up to 1 Incl FINAL
Contractor r -�p-'<u D n,.te
O
T Over 1 to IO Incl DATE ,-. 11�q Z VALIDATION 0O Over 10 to 50 Incl FINAL U
I am exempt under Sec Over 50 to 100 Inc BY W
B 8P C for this reason Over 100 t 0.
Date Services, Swbd , MCC 8 Ponelboards , Z
0-20D Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Eject
SINGLE FAMILY _Power Pole 8 Appurtenances -�I17 1� •-c
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits _,�.
Professions Code) - jI I�L 16: `-'
❑ I, as owner of the property, will do the work and the Mist Conduits 8 Conductors (_�EC 1,
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ oil.
Business and Professions Code)
it �[
CONSTRUCTION LENDING AGENCY r
I hereby affirm that there is a construction lending agency for - ) i 1 'I 91Iiicl__ji lilt -p! �r
the performance of the work for which this permit is issued PERMIT FEE _ (Sub Total) /
(Sec 3097, Gv C )
PLAN CHECKING FEE
Lender s Name PERMIT ISSUING FEE
Lender's Address
I certify that 1 have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all Count' - d
ordinances and Stole jaws regulating Electrical wiring, and /� �� ✓ ,
hereby authorize representatives of this County to enter upon
the above mentioned pro ty for inspection purposes '
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of of Peerrmnitee s Dote
DEC
TION
WORKERS't I have
a certificate
cafe of corse ,aaalR�w�r� APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm That haver certificate of consent to self a
insure oro copy thereof
of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
«a certified copy Thereof (Sec 3800, Lab C ) -
Pol�cy No Company edham FOR APPLICANT TO NLA ut !OB
Certified copy is hereby furnished New Resident Bldgs 8 Pgole ., EACH NO FEE ADDRESS �da /V s
❑Certified copy is filed with the coun7 building mspec J 8 2-Family, Sq Ft�s�•�%a f dal — $ LOCALITY )
lion deportment Multi family Sq Ft NEAREST
ST ` o
Date 3 �)j{ Applicant rN'���� — Residential Swimming Pools =
r FIRM NAME ]
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets ReZ`G.�Light_SwMAIL r
COMPENSATION INSURANCE ADDRESS -
(This section rood not be completed H wFirst 20 the work Involved by Total No Additional CITY Tel N
the pormR Is for ono hundred dollars ({100)or leu) RAN CHECK /
I certify that in 'he performance of the work for which this APPLICANT 1
permit is issued, I shall not employ any person in any manner Li titin Futures First 20 ADDRESS
so as to become subject to the Worker Compensation Laws 9 0
Total No � Additional
Dote Applicant CITY Tel No
NOTICE TO APPLICANT If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers' Range— Heater DW _ APPLICATION C
Compensation provisions of the Labor Code, you must forth- Oven Dryer a:W M ADDRESS / 7/0 ST
with comply with such provisions or this permit shall be Top FAU —WH � �
deemed revoked CITY s p-3tiA.f Tel No )^9
LICENSED CONTRACTORS DECLARATION Hood Fon —Other_
hereby affirm shot I am licensed under provisions of Chapter 9 Disp Room Au Cond LICENSE �J p
REG NUMBER J J Class G-/Q
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO ESSED BY a
and Professions Code and my license is in full face and effect p
,{ p Size b Type HP KW KVA «KVAR ,oO G(��/ O
License Number JT�rr9(1 3 Uc Class ,-}/n Up to 1 Incl FINAL O
'F cYa J E/1f//L6] 3 a4 ,L Over 1 to IO Intl DAA 11-` ` VALIDATION 0
Contractor ate Over 10 to 50 Incl l-
❑ 1 am exempt under Sec Over 50 to 100 Inc BYE W
B 8P C for this reason Over 100 a
Se�aue-bwbd-,.MCC 8 Panelboards , I
U)
Date
0 200 Am nder 600 V
Signature 201 1000 Amp Under 600V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Moms Elect n
SINGLE FAMILY Temp Power Pole 8 Appurtenances t t s
HOME OWNER-BUILDER DECLARATION -! ( ,i
I hereby affirm shot I am exempt from the Contractor s License Sign with One Branch Circuit
Low for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits `��i� Zf'S.FIS
Professions Code) I' 11_l7.
. � a
❑ I, as owner of the property, will do the work and the Misc Conduits 8 Conductors
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ �_l j�- 166 05
Business and Professions Code) I , CHECK 1s'! I_.
CONSTRUCTION LENDING AGENCY ( CH�NGF ,fill
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) � Q t l ,
(Sec 3097, Civ C ) f
PLAN CHECKING FEE - ' ?�
Lender s Name ��ir:
PERMIT ISSUING FEE ;h' 6 1 AM ):,t:
Landers Address -
I certify FEE 46 y that I have rood this application and state that the 6,�
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 inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE r
Signalute of Permittee ° Date -
WORKERS CI have COMPENSATIONDECLARATION
of copse pooivovvaiey APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to set( ��
Insure or a certificate of Workers'Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS `
or a certrfiedcopy thereof(Sec 3800 b C ]
P I cy No Com 9 FOR APPLICANT TO FILL IN , lOB
Certified copy is hereby furnished a �✓ New Residential Bldgs 8 Pools EACH tJ0 FEE ADDRESS -�
Certfed copy is filed with the county building mspec- 1 8 2-Family Sq Ft S = S LOCALITY
tion departmenJ Multifamily Sq FI NEAREST
(,x/
Residential Swimming Pools RSTOR
esien
Date 3�' - Applicant -(
FIRM
NAME
CERTIFI TE OF EXEMPTION FROM WORKERS r i • +, t ` MAIL
COMPENSATION INSURANCE Outlets Rec_Light_Sw— ADDRESS
(flits stolon r not un completed IF the work Inrolred by Fiat 20
Total No Additional CITY Tel No� _
the permit Is Foror a"hundred dollop (5100)or Ins) t RAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
Additional
Dote Applicant Total No CITY Tel No
Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT If, after making this Certificate of APPLICATIONI -
Exemption, you should become subject to the Worker Range— Heater—D W
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS S
with comply with such provisions or this permit shall be Top — FAU —W H — 0
deemed revoked S-
Hood Fan —Other—
CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR p
Dup — Room Au Cond — REG NU R 4/'T•( 7(PS Class C_
I hereby affirm that I am licensed under provisions of Chapter 9
I (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PROCESSED BY d
and Profmions Code and my license is in full force and effect
Size 8 Type HP KW KVA or KVAR Q
License Number 4 -,r"/�83 Lic Class C -/D Up to 1 Incl FINAL
ContractorC ^^- tea to -fid- Over 1 to 10 Ind D'4� r'Z •-� VALIDATION Cr
❑ Over 10 to 50 InclFINAL U
I am exempt under Sec Over 50 to 100 Inc BY W
B 8P C for this reason Over 100 d
Services, Swbd, MCC 8 Ponelboards , , - ?W
Dote
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
OOver 1000 Amp or Over 600 V
Exemption for Reg Mamt Elect )
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION ,Temp Power Pole 8 Appurtenances
Sign with One Branch Circuit •I
I hereby affirm that I am exempt from the Contractor s License ;-7 •T
Low for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits
Professions Code) :,607 1v6.0=
❑ I, as owner of the property will do the work and the Mix Conduits 8 Conductors 1 I'I EC1c
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— oil. T. 1(1_q�L 166 - 05
Business and Professions Code) `
CONSTRUCTION LENDING AGENCY + ' HE���C��K-r- lc 1.0c'
I hereby off irm that there is a construction lending agency for r�r9w]C ,00_'
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) Q
(Sec 3097 Civ C ) - ,
PLAN CHECKING FEE � t
Lender s Name
PERMIT ISSUING FEE rn 7
Lender s Address
I certify that I have read this application and stare that the TOTAL FEE
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 inspection purposes •-
SEE REVERS!FOR EXPLANATORY LANGUAGE
ms
Signature of Permittee Dot