The URL can be used to link to this page

Home My Public Portal About5325 WELLAND AVE_Electrical__ "'..,WORKER'S COMPENSATION DECLARATION 7BBAA6g3 DPW 9169 r�1 on,P C A TION FOR EI�E�IsTMCAL PERNT I hereby affirm that I have a certificate of consent to self Insure, d�l>'If'I� 8� 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.. CompanyFOR APPLICANT TO FILL IN EACH NOFEE ADDRESS �'3 a S L� FL L ,►® qv Certified copy Is hereby furnished. New Residential Bldgs.&Po9 5 — $ . LOCALITY t^�.pLer C ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $_ NEAREST ` department. Multi-family Sq.Ft. CROSS ST. F4 Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK, PAGE F RCEL CERTIFICATE OF EXEMPTION FROM'WORKERS' ,Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAME First 20 4AAIL (This section need not be completed if the work involved by the I Total No. Additional ' ADDRESS permit Is.for one hundred dollars($100)or less.) I certify that In,the performance ofthe work for which this permit CITY Tel.No. is Issued, 1 shall,not employ,any person in any manner so as to i become subject to the Workers'Compensation Laws. (:Lighting Fixtures First 20 PLAN CHECK APPLICANT Total No. Additional ADDRESS Date Applicant I NOTICE TO APPLICANT: If, after making this Certificate of 15 OR 20A,120V BRANCH CIRCUITS CITY Tel.No. Exemption,you should become subject to the Workers'Compensation '1 TO 10 INCLUSIVE EACH PERMIT provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT C+ � � ��i L -provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS• 2 3 G/W/ &L nS/Y 4•Q d, 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 f� (, Tel Na. d3�7 / d Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Power Apparatus&Large Appliances REG.NUMBER 44 F_ Class, �"] O License Number L�Ll Lic.Class G i Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY U r-le ' l�OCc (�C Up to3lncl. •gyp. LU Over 3 to 10 Incl. FINAL a. Contraotbbbr. Data { Over 10 to 50 Incl. DATE ❑ I am exempt under Sec. Over,50 to 100 Incl. I 2 6 VALIDATION Over 100 BY AL B.&P:C.for this reason ' , Services,Swbd.,MCC&Panelboards Date: Aze� 0 200 Amp.Under 600 V Slanature� I 201-1000 Amp.Under 600 V i ❑ Over 1000 Amp.or Over 600 V " Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 'S •�' with One Branch Circuit I hereby affirm that I•am exempt from the Contractor's License Law Sign w for the following reason. (Section 7.031.5, Business and Professions Additional Sign Branch Circuits 'µ3- 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) ;I•-'`AL 1.1 d, 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 i:W"" r'_' :a- 0.- J-%.? Lender's Name l•F .t:it L j 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 propert forinspec' urpo s. _ SEE REVERSE FOR EXPLANATORY LANGUAGE SIG TORE OF AWLICANTORAGENT DATE rN KER'S COMPENSATION DECLARATION I DPW 9/89 APPLICATION MA ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self Insure, 'M�A663� or a certificate of Worker's Compensation Insurance, or a certified I COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereo(ASec.3800 Lab.C.) Policy No. Company ��' FOR APPLICANT TO FILL IN JOB ADDRESS Y Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE $ _ $ , LOCALITY ❑ Certified co is filed with the county building inspection 1&2-Family,Sq.Ft. PY tY 9 P NEAREST r^ ,daps nt., 1 d Multi-family wi Ft. CROSS ASSESSOR C(� Date �l.11 / Applicant Residential Swimming Pools MAPBOOK MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE First 20 FIRM NAME (This section need not be completed if the work Involved by the ADDRESS permit Is for one hundred dollars($100)or less.) , Total No. Additional I certify that in the performance of the work for which this permit CITY I NA 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 �PUCIANT A&f.l �� provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESSG- I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH Q (commencing with Section 7000)of Division 3 of the Business and CITY rel.No V Professions Code,and my license is In full force and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE o L class. Power Apparatus&Large Appliances � REG.NUMBER Q 4-77 7� Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY V License Number Lic.Class P �� —� C U to3lncl. �0� III r/!�� Over 3 to 10 Incl. FINAL a � Contractor � O� Date DATE / 11Over 10 to 50 Incl. I am exempt under Sec. I Over 50 to 100 Incl. VALIDATION B.&P.C.for this reason Over 100 BY AL Services,Swbd.,MCC&Paneiboards 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&Appurtenance ✓� :I" HOME OWNER-BUILDER DECLARATION t' th One Branch Circuit 1 hereby affirm that I am exempt from the Contractor's License Law :r. for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits -ti•%y -+�s = 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) - L-••-':2 and Professions Code). ® *•_3 = 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.3087, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE Lender's Name 06 7 PERMIT ISSUING FEE Lender's Address "c t t I have read this pplicatlon,and state that the above TOTAL FEE informal' is correct. I agr to comply with all County ordinances , and St a lave: regulatin lectrical wiring, and hereby authorize repres t tives of this ty to enter upon the above-mentioned prope fpr inspection p oses. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATJRf OF APPLICANT OR#IGENT DATE WORKER'S COMPENSATION DECLARATION 120.0019 DPW 9189 �° p� 1 hereby affirm that I have a certificate of consent to self insure, '7SA883 APPLICATION-FOR ELE;'Aa�a Tki®IC AL PEE" MIT or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereofR 3800 Lab.C.) c1�9 '' Policy N Company �_ FOR APPLICANT TO FILL IN JOB �z. Certified copy Is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY el e ❑ M Ft Sq. . TJ Certified copy is filed with the county building inspection 1&2-Family, $ _ $ NEAREST,4113p1 aMufti-family Sq.Ft. CROSS �� Residential Swimming Pools ASSEsBOR Date Applicant z it MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. PRM NAME ) COMPENSATION INSURANCE (This section need not be completed If the work Involved by the First Additional ADDRESS MAIL Total No. Additio permit is for one hundred dollars($1.00)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 Q become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANTA.d a_ /V Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS LAroa-0 NOTICE TO APPLICANT: If, after making this Certificate of CITY TeI.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 APPLICANT provisions or this permit shall be•deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION IADDRESS > I.hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH 0. (commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. C Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR �7 Power Apparatus&Large Appliances REG.NUMBER 4 i? Class..J o License Number Lic...Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY u f. p V �^ Up to 3 Incl. CL Contractor a�–—�0 Date ^ Over 3 to 10 Incl. DAA w CL Over 10 to 50 Incl. � �S❑ Z I am exempt under Sec. Over 50 to 100 Incl. VALIDATION BAP.C.for this reason Over 100 FINAL- Services,Swbd.,MCC&Paneiboards ,Date: 0-200 Amp.Under 800 V Signature 201-1000 Amp.Under 800 V Over 7000 Amp.or Over 600 V Exemption for Reg.Maint:Elect. .a4:I{• 3,: : SINGLE FAMILY p:Power Pol Appurtenances , HOME OWNER-BUILDER DECLARATION ,t. T 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 i 5_i �.% 2,.�'y=. 601. Code): 67 I,as owner of theproperty,will do the work and the structure Misc.Conduits&Conductors •a A Is,not intended or offered for sale(Section 7044,,Business Other(See Complete Fee Schedule) and Professions Code). CONSTRUCTION LENDING AGENCYI j f Lir= I hereby affirm that there is a construction lending agency for the "3 ` performance of the work for which this permit is issued(Sec.3097, PERMIT FEE Sub-Total) (Zett 3364 Ar. % Y':.? Civ.C'.) PLAN CHECKING FEE Lender's Name C ' PERMIT ISSUING.FEE Lender's Address I certify t have read this.application and state that the above TOTAL FEE 3, informati i .correct. I agree to comply with all County ordinances and St a Is s regulating I ctrical Iring, and hereby authorize I repres tall es of this Cc to a er upon the above-mentioned propdt for Inspection pur a. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE IF APPLICANT OR AG DATE ' I �