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Home My Public Portal About9217 WEDGEWOOD ST_Electrical__ �ff ER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) \ I hereby that I have a certificate of consent to self insure, 76A663 APPLICATION FOR ELECTRICAL PERMIT LLLIII or a-eaitificgte-of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof sSec.3800 Lab.C.) policy NO. Company FOR APPLICANT TO FILL IN JOB — ADDRESS ❑ NO. EACH FEE ? J, Certified copy is hereby furnished. New Residential Bldgs.&Pools _ $ $ LOCALITY V ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST ! r department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR p� MAP BOOK d ppGE. I PARCEL. /6 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. WNER OR COMPENSATION INSURANCE FIRM NAME (This section need riot be completed if the work involved by the First 20 MAILTotal No. Additional ADDRESS permit is for one hundred dollars($100)or less.) 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 i- '' "Applicant r RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTIC TO APPL CANT: If, after making/this Certificate of CITY Tel No. Exemption,you should become subject to theWorkers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PRM.ICANT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances 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. n (commencing with Section 7000)of Division 3 of the Business and CITY �r +'Tel.No. !/ f� Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENS9 OR Class. a Over 50 to 100 Incl. REG.NUMBER r 0 • / Over 100 DISTRICT NO. P C SED BY V License Number _ y Lic.Class G ! Servlc�/�s`'/S8 bib 41CC&Panelboards � e t..J O Contractor A� Q- Date 1�_ �/ CA•m�p.Under 600 V FINAL / DATE n I" ®� I am exempt under Sec. �^ /J 0- 000 Amp.Under 600 V F "' Z` v VALIDATION W Over 1000 Amp.or Over 600 V FINAL d B.&P.C.for this reason �/ BRANCH CIRCUIT FEES BYCO Date: / ,/E� �- 15A,or 20A,120V,Lighting or Recept. / G1 To 10 Branch Circuits Signature ✓ Ir— N 11 To 40 Branch Circuits / 41 Or More Branch Circuits Exemption o eg.Maint.Elect. ^15A,20A,2D8V To 277V Lighting Br.Circuits / SINGLE FAMILY Temp.Power Pole&Appurtenances _ s HOME OWNER-BUILDER DECLARATIONSign 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 L _ Code): „ ❑ ± EI`'' 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) ® i I;LIL' ,—,. 7 and Professions Code). _ CONSTRUCTION LENDING AGENCY ' i�- I hereby affirm that there is a construction lending agency for the j 'T= Performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE Lender's Name .y/ PERMIT ISSUING FEE O`(O 1 tE3 °s'f' Lender's Addr ITOTAL FEE + I certify that I have read this application and under penalty of purjury state7161 that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize represent ves of this County to enter upon the above-mentioned property spe /,(fin oses. SEE REVERSE FOR EXPLANATORY LANGUAGE j314 ATURE OF PERMI EE ( 'DATE IbV. ER-S COMPENSATION DECLARATION 7°663 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT I hetebhave�a certificate of consent to self insure, or a'eerti icite oh 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. Company FOR APPLICANT TO FILL IN JOB ADDRESS J 6�..0 •..:�iJl��r( S� ac r G Certified co Is hereby furnished. NO. EACH FEE PY� Y New Residential Bidgs.&Pools _ $ $ LOCALITY ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST s- department. Multi-family Sq.Ft. CROSS ST. iL'%/7 i TdC Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Recl40—Light----3 Sw. OWNER OR y COMPENSATION INSURANCEO �y FIRM NAME (This section need not be completed If the work involved by the First 20 d MAIL permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS I certify that in the performance of the work for which this permit CITY �� T.I.No._ : is issued, I shall not employ any person in any manner so as to ,7 PLAN&ECK become subject to the Workers'Compensatio aws. Lighting Fixtures 7 First 20 41 A APPLICANT " Total No. Additional ADDRESS Date ' ` Applicantit NOTI E TO AP LI A T: If, aft aking this Certificat RESIDENTIAL APPLIANCES NOT OVER 3HP. CITY Tel.No. Exemption,you should become subj c to the This Com sat! OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code,you at forthwith comp) ith ch PERMIT r• provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT ..g ,a 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. (commencing with Section 7000) of Division 3 of the Business and CITY 2�.�.111� Tel. tl ��J Over 10 to 50 Incl. Professions Code,and-my license is in full force and effect. LICE SE OR Over 50 t0 100 Incl. REG.NUMBER \r Class. a Over 100 DISTRICT NO. P OCESSED BY i 0 License Number Lic.Class p Services,Swbd.,MCC&Panelboards �O g. for Date 0-399 Amp.Under 600 V DATE O 400-1000 Amp.Under 600 V At, V I am ex pt under Sec. FINAL VALIDATION d Over 1000 Amp.or Over 600 V B.&P.C.for this reason BY Z BRANCH CIRCUIT FEES DX J4_ — 15A,or 20A,12OV,Lighting or Recept. _ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption or eg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits r; SINGLE FAMILY Temp.Power Pole&Appurtenances — HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 330 Code): I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors .1 is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) ® T ;T 01 �jl;,} and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the `•1~ )ry?(s= =L' 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 4:1 //Q 272111 Lender's Address TOTAL FEE Q e(Q I certify that I have read this application and under penalty of purjury state that the above information is correct. I agree to comply with all County ordinandesand State laws regulating Electrical wiring,and hereby authorize representatives of is County to enter OF upon a above-mention d props y /for ins action pu sea. + / SEE REVERSE FOR EXPLANATORY LANGUAGE A, 11 Awl PJA / SIGNATU PERMI E (./� APPLICATION FOR ELECTRIC PERMIT 1 COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING / BUILDING AND SAFETY DIVISION ADDRESS JOHN A. LAMBIE, COUNTY ENGINEER , CASSATT D.GRIFFIN,SuwT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST p UCT FMS CROSS ST. �C/! 6 ' ITEM NUMBER EACH FEE OWNER _ OUTLETS: MAIL. LIGHTS RECEFT SW. $ .IO ADDRESS LIGHTING FIXTURES .10 CITY L.NO s- ELEC.RANGES . CLO.DRYERS ELECTRICIAN WATER HEATERS .$O ADDRESS ELEC.SPACE HTRB. DISHWASHERS CITY TEL.NO. GARBAGE DISPOSERS AUTO.- STATE WASHERS STA.COOKING UNITS .2$ LICENSE NO. MOTORS: OVER INC: H.P. DISTRICT NO. GROUP I ZONE P ESSED BY O— >� :28 va — 2 50 INSMCTION BECORD 2— $ 1.00 $— 15 1.50 t5- 50 2.50 50-200 5.00 SIGNS: NO.TRANS. NO.LAMPS _ 4411Y,5WACA ` A SERVICE 0-000V t.00 775 Q I' C_ THOd SERVICE OVER GOOV 5.00 L l✓ LDS a MISC. WIRING PERMIT 1.00 l -`� �r �wi 2p4'PTS Ink FIXTURE PERMIT 1.00 SUPPLEMENTARY PERMIT j $O TOTAL FEE S I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCESAND STATE LAWS REGULATING ." CONDUIT �/ �A-. p -// ELECTRICAL WIRING. WIRING COO?lY'J't/�� '2s 6 V f_7/ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS_REQUIRED BY LOS ANGELES COUNTY AND STATE OF iXTURES -'mss-a CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RES1D TIAL PROPERTY. POWER SIGNATURE ' UTILITY CO.NOTIFIED OF PERMITTE , FINAL �.Z'" f� /.'.�lll. ✓t?.� )p CKMQAT� ARTHUR C.VEIF, CK MO CASH SUPERVISING ELECTRICAL ENGINEER 6 13 951-3 ►zB 5 2 A 1.30