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Home My Public Portal About5327 WELLAND AVE_Electrical__ +' WORKER'S COMPENSATION DECLARATION 2MO19 DPW SIBS APPLICATION FOR ELECTRICAL PERMIT I hereb�r affirm that I have a certificate of consent to self insure,. or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS .BUILDING AND SAFETY DIV. ,py thered(Sec.33800 Lab.C.) /r / '0440 �,, /� Poll No. S Z Z Company s 4 TC' �N� FOR APPLICANT TO FILL IN DDRESS S _ V��y�40 Certified copy is hereby furnished. EACH NO.' FEE. Y New.Residential Bldgs.&'Pim 6 q $. _ $ LOCALITY (SyL [ I Certified co is filed with the county building Ins ection 1&2-Family,Sq.Ft. 1 PY tY 9' P EARE apart t. 7 OF Multi-family Sq.Ft. NCROs 8STT. Date �Applicarit Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM W KERS' OWNER OR L T Outlets:Rec._Light Sw. FIRM NAME COMPENSATION INSURANCE First 20' MAIL (This section need not be completed if the work Involved by the Total 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 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 PERMIT Provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT � � L provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH je y, LICENSED CONTRACTORS DECLARATION ADDRESS 3 2 r"�y (rL vS 17.. 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/,//pit) u Tel.No. /�t_:S J 0 Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Power Apparatus.&Large Appliances REG.NUMBER 3 Ll 4 CIS 7v O License Number' JLic.Class C Size&Type HP,KW,KVA,or KVAR DISTRICT NO. �y .PROCESSED BY I.. Q /e� �4� ` ^� Upto3lncl. Contractor G Date Over 3 to 10 Incl. DATAEL Pt ❑ Over 10 to.50 Incl. am exam under Sec. _ Over 50 to 100 Incl. �. VALIDATION NAL B.&P.C.for this reason Over 100 FINAL Services,Swbd.,MCC&Panelboards 0-200'Amp.Under:600 V Signature -201-1000 Amp.Under.600 V Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.E SINGLE FAMILY Temp.Power Pole&Appurtenances HOMEOWNER-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 Code): 4-i ;L`r ❑ 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) , and Professions Code). , 'f"j'�I-- ','�i_I C.: CZ/ 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.30.97, .PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address TOTAL FEE a, 9 I certify that I have read this application and state that the above Information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authoriz..e representatives of this County to enter upon the above-mentioned property for inspection SEE REVERSE FOR EXPLANATORY LANGUAGE SIGN RE OF APPLICAyr OR AGENT DATE ION '!WORKER'S I have a certificate of consent to 7BA66B139DPW 9189 APPLICATION FOR ELECTRICAL PERMIT I hereb�r affirm that I have a certificate of consent to self Insure, or a certificate of Worker's Compensation.Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. cgpy thereof(Sod.3800 Lab.C.)S I0 �- Policy No. 2,Z Company ( 9 TC° rL tey FOR APPLICANT TO RLL IN JOB ADDRESS ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE 1'�`6 $ S LOCALITY 04 1&2-Family,Sq.Ft. [ f $ — Certified copy Is filed with the county building inspection _ NEAREST apart Multi-family Sq.Ft. CROSS BT, a Z Residential Swimming Pools Date Applicant MAP BOOR . MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM KERS' OWNER OR COMPENSATION INSURANCE Outlets:Red._Light Sw. FIRM NAME L First 20 MAIL (This section need not be completed If the work Involved by the Total 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 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 PERMIT P Y P Y APPLICANTTC- �� ZrC •��. provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >_LICENSED CONTRACTORS.DECLARATION ADDRESS 3 2 "� GTL o S d I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,2 �6.LJ 0BV TO 277V LIGHTING EACH O (commencing with Section.7000)of Division 3 of the Business and CITYG// 1) u Tel.No. 5 0& J C) Professions Code,and my license is in full"force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR 7 /-} Power Apparatus&Large Appliances RECL NUMBER .7 L4 4 Class. G 7(� O License Number, J� C� Lid.Class a Size&Type HP,KW,KVA,or KVAR DISTRICT NO. ry PROCESSED BY Irry Contrealor ' Date Over 3 to 10 Incl. FINAL CL ❑Over 10 to 50 Incl. � I am exempt.under Sec. Over 50 to 100 Incl. `u VALIDATION FINAL B.&P.C.for this reason Over 100 BY Services,Swbd.,MCC.&Panelboards 0-200 Amp.Under 600'V Signature 201-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.E act. :SINGLE FAMILY Temp:Power Pole•&Appurtenances .-��°"'j�;r]'�,'F�y �+ HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License.Law' Sign with One Branch Circuit tr. yv L for the following reason (Section'7031..5, Business and Professions Additional,Sign Branch Circuits- `" Code): pt„S i i tF° ❑ 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) ;. and Professions Code). ► L r;r'S.; _; tL:IF?'� CONSTRUCTION LENDING AGENCY ^'`"lei _ All 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 Lender's Name PERMIT ISSUING FEE Lender's.Address q 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 property for Inspection g�� SEE REVERSE FOR EXPLANATORY LANGUAGE SIGN RE OF APPLICA11 OR AGENT DATE