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Home My Public Portal About5502 WELLAND AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.91) I) L( I hereby affirm that I have a certificate of consent to self Insure, 76A663 APPLICATION FOR ELECTRICAL PERMIT • or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANG S DEP O PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) �q j ' ) y p Policy No: Company FOR APPLICANT T ILL IN Joe ADDRESS SSo.? (�{�`1.�f�/y ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. FJ\CFI FEE ❑ _ $ $ NE LOCALITY Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR /�IJT�ON �� COMPENSATION INSURANCE Outlets:Rec. Light Sw. a� FIRM NAME /�- /CJ First 20 6 MAIL (This section need not be completed If the work Involved by the Total No. Additional ADDRESS 5 a2 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. L 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 such PERMIT p p y 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. LICENSEClese } Over-50 t0 100 MCI. REG.NUMB ER 0. Over 100 DISTRICT NO. R BSED BY 0 License Number Lie.Class Services,Swbd.,MCC&Panelboards t�d Contractor Date 0-399 Amp.Under 600 V FINAL 0 ❑ - 400-1000 Amp.Under 600 V I am exempt under Sec. VALIDATION Over 1000Amp.or Over 600 V LU B.&P.C.for this reason FINAL d BRANCH CIRCUIT FEES (n 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,MA,208V To 277V Lighting Br.Circuits 2 SINGLE FAMILY Temp.Power Pole&Appurtenances i r( a HOME OWNER-BUILDER DECLARATION ACCT.a Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law � rr, ('rc, for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits :�31I-).F 2DOL` Codes i t l EMS Misc.Conduits&Conductors I,as owner of the property,will do the work and the structure t• is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) Tjf i AL , and Professions Code). ® t� 52.O' �iE � CONSTRUCTION LENDING AGENCY CHANGE nv�l I hereby affirm that there is a construction lending agency for the `t performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) 4— Civ.C.) __ PLAN CHECKING FEE 0000-13CUI 9/28/93 Lender's Name PERMIT ISSUING FEE 1vr1` ArI °+�- Lender's Address TOTAL FEE 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 ordinances and State laws regulating Electrical wiring,and hereby authorize representatives of this Cou ty to enter upon the above mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE (at-, �Ae� SIGNATURE OF PERMIr,r8ffE P DATE WORKER'S COMPENSATION DECLARATION 200079 DPW 9/e9 ��oa�q��®1�1 ®® ��L PERMIT 76A683 APPLICATION N fl 11t I hereby affirm that I have a certificate of consent to self insure, or a certificpte 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. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY ❑ $Ft $ S Certified copy is filed with the county building inspection 1&2-Family, q. . _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAME (This section need not be completed if the work involved by the First 20 -MAIL �G- permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS 432V U4550AA1,9 I certify that in the performance of the work for which this permit I CITY '� T.I.No. is issued, I shall not employ any person In any manner so as to PLAN CHOCK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT • p g I._. Total No. Additional ADDRESS Date d Applicant Total 15 OR 20A,120V BRANCH CIRCUITS NOTICE TOA POCANT: If, after makin 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 ERMIT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS 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 CITYJ. Tel.No.Azov Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR 0: Power Apparatus&Large Appliances REG.NUMBER Class. O Size&Type HP,KW,KVA,or KVAR 1 DISTRICT NO. PROCESSED BY License Number Lic.Class 1 , n� s •tee Up to 3 Incl. �vt� d Contractor Over 3 to 10 Incl. FINAL ,Vg ,!3 nate DATE _ N Over 10 to 50 Incl. t "' ❑ I am exemptc. Over 50 to 100 Incl. —2 S / VALIDATION Over 100 FINAL B.&P.C.for this reason BY Servi CC&Panelboards Date: 0-200 Amp. nder 600 V Signature ----%2_0i2 p.Under 600 V ❑ Over 1000 Amp,or Over 600 V Exemption for Reg.Maim.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances i HOME OWNER-BUILDER DECLARATION I Sign with One Branch Circuit CCT E I hereby affirm that I am exemptfrom the Contractor's License Law g _ ACC� e s fdr the following reason(Section 7031.5, Business and Professions I Additional Sign Branch Circuits ,-_. _ Code): 77.03 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors j ITEMS is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) 1+ � and Professions Code). ® TOTAL . CONSTRUCTION LENDING AGENCY I CHEICK 77.03 1 hereby affirm that there is a construction lending agency for the CHANGE performance of the work for which this permit Is Issued Sec. 3097, X P P ( PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE Lender's Name. 0000-0001 q/16/9_' i PERMIT ISSUING FEE cg i t Lender's Address - 540155 1 AM 10:59 I certify that I have read this application and state that the above TOTAL FEE �� 3 information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of4his County to enter upon the above-mentioned propert Ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I SIGNATURE OFAWr OR R6 4 1 E , WORKERS'COMPENSATION DECLARATION 78-883 10/81 CE-806G APPLICATION FOR ELECTRICAL PERMIT I hereby afArm that I have a,certificate of consent to self insure, or aificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cop57tt�reof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB r�0 Z ��1 t LLAVP ❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS ] tN �/ New Residential Bldgs.&Pools r, � ❑ tZL 1 &2-Family,Sq.Ft. $ — $ LOCALITY ( ({� Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. — NEAREST r CROSS ST. D OLl iie4 P Ir Residential Swimming Pools Date Applicant OWNER OR FlRM NAME (7 U N CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Reci-t Light.�Sw..� MAIL .� COMPENSATION INSURANCE 14 t ADDRESS (This section need not be completed If the work Involved by the First 20 permit Is for one hundred dollars($100)or less.) Total No.. Additional CITY �,L �� Tel.N g�Zg(^gZZ I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person In any manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If,• after making this Certificate of PERMIT Exemption,you should become subject.to the Workers'Compensation Range_ Heater_ D.W. APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be'deemed revoked. Top _ FAU _ W.H. _. CITY -Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Professions Code,and.my license is in full force and effect. Power Apparatus&Large Appliances DISTF Cl'f10� PRO SED gY, a Size&Type HP,KW,KVA,or KVAR �4/� Q License Number Lie.Class Up to 1.Incl. FINAL `� V Over 1 to 10 Incl. DATE l/ G v VALIDATION O Contractor Date Over 10 to 50 Incl. FINAL. V ❑ I am exempt under See. Over 50 to 100 Inc. BY �'�rj• a B.& P.C.for this reason Over 100 G!/ Dater Z Services,,Swbd.,MCC&Panelboards ® 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V e7 i SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCTA 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 3307 27.011 Code): 1 ITEMS L1511 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) _ Poo. TOTAL 27 -00 and Professions Code). CASH 27000 CONSTRUCTION LENDING AGENCY a CHANGE a011 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 0000—mo1 9I ufG$ Lender's Name PERMIT ISSUING FEE W9 I AM 9°a5 Lender's Address ' 1 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 OZ7 Im and State. laws regulating Electrical wiring, and•hereby authorize. representatives of this County to enter upon the above-mentioned property for inspection purposes. , YSeig!n::.�t SEE REVERSE FOR EXPLANATORY LANGUAGE n�� ~ 'ure oftmitt e ' ( - Date