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HomeMy Public PortalAbout6003 AGNES AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT I iaereby afifirm that I have a certificate of consent to self CE-806G r she;`ory cern`#icate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL.IN. JOB pit/ Certified copy is hereby furnished. EACH NO. FEE ADDRESS New Residential Bldgs. & Pools '1 ❑ /J.Q 4 Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY µ tion department. Multi-family Sq. Ft. —'NEAREST CROSS ST. OWNER T. Residential Swimming Pools Date Applicant OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' RIP Outlets: RecLightSw.� MAIL ! COMPENSATION INSURANCE ADDRESSnes /�/ � > � First 20 (This section need not be completed if the work involved by CI (Cis . Tel. No. - the permit is for one hundred dollars ($100)or less.) Total No. Additional PLAN 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 Total No. 1)�- CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making this CeFixed Appliances Not Over 1 HP PERMITrtificate of APPLICANT Exemption, you should become subject 'to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W.H. deemed revoked. Hood _ Fan _Other CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the BusinessffCe 11 n� t� DISTRICT NO. PROCES ED BY and Professions Code,and my license is in full force and effect. Power Appar . us& Large Appliances ®� O Size &Type HP, KW, KVA, or KVAR' l IL License Number Lic. Class Up to 1 Incl. FINA Over I to 10 Incl. DATE VALI TION Contractor Date Over 10 to 50 Incl. ❑ I FINA am exempt under Sec. Over 50 to 100 Inc. BY A B.&P.C. for this.reason Over 100vado V) Date: Services, Swbd., MCC & Panelboards ► 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V EJ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. , #ray <� SINGLE FAMILY Temp. Power Pole &Appurtenances K r t• HOME OWNER-BUILDER DECLARATION Sign 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 Additional Sign Branch Circuits Professions Code): _;( 0.02,9 0;0. I, as owner of the property, will do the work and the Misc. Conduits &Conductors structure is not intended or offered for sale (Section Other(See Complete Fee Schedule) e,2.q, (7 Q c=i. ' 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE 6 above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and her by authorize representatives of this County to enter upon th above-meAfti4m� property for inspection purposes. 2SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permittee Date WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O 76A663 11 h6reby affirm that I have a certificate of consent to self CE-806G insure' or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB 2 { n Q Certified copy is hereby furnished. Ne Residential Bldgs. & Pools EACH NO. FEE ADDRESS �J / �v L r Certified copy is filed with the county building inspec- 1 2-Family, Sq. Ft. �_?�� $ _ $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Residential Swimming Pools OWNER OR Dare Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' L g IL I n Outlets: Rec Li ht Sw.a MAO /� ADDRESS 711ws COMPENSATION INSURANCE First 20 (This section need not be completed if the work involved by Total No. ` 5 .CITY, F J Tel. No the permit is for one hundred dollars (;100)or less.) Additional F PLAN 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 Fixtur First 20 ADDRESS Total No. Date Applicant Additional CITY Tel. No.Fixed Appliances Not Ov r 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION Lr Exemption, you should become subject to the Workers' Range— Heater D.W. Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITY Tel. No. Hood Fan —Other— LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. — Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P O SSED BY d and Professions Code, and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR o License Number Lic. Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE �Z3 • VALIDATION Cc0 Contractor Date Over 10 to 50 Incl. U FINAL I am exempt under Sec. Over 50 to 100 Inc. BY U.1 B.&P.C. for this reason Over 100 11 Services, Swbd.., MCC& Panelboards , Z_ Date: 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V aExemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Tem Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION p' pp I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit o,F Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Xo essions Code): I, as owner of the property, will do the work and the Misc. Conduits& Conductors �(?. \\structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ r L Business and Professions Code). , ;1s mat_ 4e 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 PERMIT FEE (Sub-Total) a Q _s I�: :a1 =j»t'-' (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address /'� = :; ";z:_) a I certify that I have read this application and state that the TOTAL FEE , 7f/ above information is correct. I agree to comply with all County ordinan es and Stat laws regulating Electrical wiring, and r hereby uthorize r se tatives of this County to enter upon the ab ve-me do p erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Si4kWe of Perrh#tje7 Date WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby cEfirm that t have a certificate of consent to self CE-806G ins6re' or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB /� Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH . NO. FEE ADDRESS ® 3 a ne S Am- Certified copy is filed with the county building inspec- 1 & 2-Family, 5q. Ft. LOCALITY $ — $ tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. WOO�A V L 1� Residential Swimming Pools OWNER OR ;(� _ i Date Applicant FIRM NAME LnU1 S �t CaL iJ{U CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw._ MAIL COMPENSATION INSURANCE g ADDRESS 60D ( s seneenoe completed if the work involved b 3 / nP /►1/C — (This d t be lFirst 20 g Y Total No. Additional CITY��v, J Tel. No. 5-g4/ the permit is for one hundred dollars ($100)or less.) PLAN 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 becom subject to the Wor ers'Com ns tionL Total No.a S— Lighting Fixtures First 20 ADDRESS Additional CITY Tel. No. Date Z S 87 Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE T APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven — Dryer — W.M.— ADDRESS NP with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. Hood Fan _ Other_ CITY U Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESS p� Power Apparatus& Large Appliances and Professions Code,and my license is in full force and effect. "� O Size& Type HP, KW, KVA, or KVAR' o V License Number Lic. Class Up to 1 Incl. FINAL IY Contractor Date Over 1 to 10 Incl. DATE j - VALIDATI N ❑ 9 7 Over 10 to 50 Incl. FIN W I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 U)Z Date: 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 # �4'� SINGLE FAMILY Temp. Power Pole & Appurtenances ( ° - 2550 = HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit O 2'0�55 9 9 v 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Pro essions Code): I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address O I certify that I have read this application and state that the TOTAL FEE i above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and here y authorize r presentatives of this County to enter upon the Bove-menti d i erry for inspect'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i nature of Per ittee Date WORKER S'COMPENSATION DECLARATION CE-806G (2-80) APPLICATION .FOR ELECTRICAL PERMIT I hereby affirm that I have a"certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY ,insure,.or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) FOR APPLICANT TO FILL IN JOB _ Policy No. Company ADDRESS New Residential Bldgs.&Pools EACH NO. FEE Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY le l Multi-family Sq. Ft. NEAREST ' 12LA�P � Certified copy is filed with the county building inspection CROSS ST W0 department. Residential Swimming Pools OWNER OR6/� ll ��0 ,� �y FIRM NAMEt � �r` :S Date ApplicantOutlets: Rec._Light Sw. MAIL First 20 ADDRESS _ CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY I ' f",PLIa C (YTel No. ';)�81—{�j� COMPENSATION INSURANCE PLAN CHECK d 1 (This section need.not be completed if the work involved APPLICANT 0 by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS 0 Additional I certifythat in the Total No. Q performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. . permit is issued, I shall not a ploy any peri m-any manner PERMIT a so as to become subject to th Workers' ompe tibn Laws. Range_ Heater_D.W. ° APPLICANT to /� t Oven _ Dryer_W.M. ADDRESS � Date 0-2(C— 'Applicant Top _ FAU _W.H.. — Hood — Fan _Other_ CITY Tel No. `NOTICE TO APPLICANT: If, after mai g this Certificate Disp. _ Room Air Cond.— LICENSE OR Exemption, you should become subl ct to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. Up to 1 Incl. Over 1 to 10 Incl, DATE FINAL ' LICENSED CONTRACTORS DECLARATION ' VALIDATION Over 10 to 50 Incl. I hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc. FINALBy / 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 .E a w ness and Professions.Code, and my license is in full force and effect. Services 0-200 Amp. Under 600 V License Number Lic.Class 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole& Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): ' 1 6 9,0 A Misc.Conduits& Conductors I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 0 0 0 0 0 2 structure is not intended or offered for sale (Section 7044, Business and Professions Code). 2 0 0 1 9,5 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency _ for the performance of the .work for which this permit is PERMIT FEE (Sub Total) o 0 0 1 9,5 0 v issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) .1 0 2-67 8 1 Lender's Address PERMIT ISSUING FEE ®O I certify that I have read this application and state that the TOTAL FEE �D above information is correct. I agree to comply with all County or finances and St s regulating Electrical wiring, and her by authori represent tives of this County to enter upon 1,t bore-men Toned p periy for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ignature f Permittee Date