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Home My Public Portal About5319 BALDWIN AVE_Electrical__ (2) WORKERS'COMPENSPTION DECLARATION CE-803 1081 APPLICATION FOR ELECTRICAL PERMIT I. �y affirm that I have a certificate of consent to self insure, . CE-806G dl -ertificate of-Worker:iCompensation Insurance, or a'certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cop•;ateof(Sec.3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified co is hereby furnished. EACH NO. . FEE ADDRESS Py Y New Residential Bldgs.&Pools ❑ 1 & 2-Family, Sq.Ft. $ _ $ LOCALITY 3 4 N V Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. NEAREST CROSS ST Vpr . Date Applicant Residential Swimming Pools OWNER OR 1 ' �� FIRM NAME W CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec �' L Light � Sw. ,1 �� / MAIL Gf2 COMPENSATION INSURANCE ADDRESS S 3 I N IJ v (This section need not be completed if the work involved by the 571 First 20 permit is for one hundred dollars($100) or less.) Total No. Additional CITY T Tel. No. 4 �, Q PLAN CHECK I certify that in the performance of the work for which this permit APPLICANT 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 9 Additional 9 U C tal No. CITY Tel.No. Date Applicant �M�N�, NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP 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 S Z St provisions or this permit shall be deemed revoked. Top — FAU 1 W.H. _ �O LICENSED CONTRACTORS DECLARATION Hood — Fan OtherCITY Tel.No. _ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR REG.NUMBER s' D 41 f Class. C (commencing with Section 7000) of Division 3 of the Business and J Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. /, PROCESWD 1 CL Size& Type HP,KW,KVA,or KVAR i v O ' License Number a yA4 Lic.Class Up to 1 Incl. FINAL /►p ;__ C/YWV l7 Over 1 to 10 Incl. DATE Contractor�/f�^'^" Date VALIDATION(y 0 Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec.�� / Over 50 to 100 Inc. gY 1.1U BAP.C. for this reason Over 100 p. Date: Services, .,MCC& Panelboards N 0- 0 mp.Under 600 V %/ "M Signature 201 - 00 Amp. Under 600 V ACCT.AT ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V 3307 110o90 SINGLE FAMILY Temp. Power Pole& Appurtenances 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 Professions Additional Sign Branch Circuits Code): ❑ I,as owner of the property,will do the work'and the structure Misc.Conduits & Conductors is not intended or offered for sale ( sSection 7044, Business Other (See Complete Fee Schedule) � ITEMS and Professions Code). CONSTRUCTION LENDING AGENCY TOTAL 10 m 90 1 hereby affirm that there is a construction lending agency for the (;HECK 110.90 performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) 7 �� Civ.C.). CHARGE PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 9 01000-000 1 9/ 1/913 Lender's Address 1 certify that I have read this application and state that the above TOTAL FEE pQ � AM 9:04 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 prop f nspection r ses. SEE REVERSE FOR EXPLANATORY LANGUAGE - __ _ iK� I I � I 90 Signature of Permitt e Date WORKERS'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 SOB Policy No. Company EACH NO. FEE ADDRESS �� New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Famiiy,Sq. Ft. $ — $ LOCALITY ,. ❑ Multi-family Sq. Ft. NEAREST " Certified copy is filed with the county building inspection CROSS ST ['� department. Residential Swimming Pools OWNER OR FIRM NAME fiC I. SL ) / Date Applicant Outlets: Rec._Light First 20 ADDRESS .CERTIFICATE OF EXEMPTION FROM WORKERS' Total No, Additional CITY Tel No. 7 117- COMPENSATION INSURANCE PLAN CHECK 0. (This section need not be completed if the work.involved APPLICANT O b the permit is for one hundred dollars Lighting Fixtures First 20 y p ($100) or less.) ADDRESS Total No. Additional fr I certify that in the performance of the work.for which this CITY Tel No. O permit is issued, I shall not employ Any person in any manner Fixed Appliances Not Over 1 HP U PERMIT so as to become subject to.the Workers' Compensation Laws. Range_ Heater O- D.W. APPLICANT gEE�GTi2/L UJ d Oven Dryer_W.M._ ADDRESS 3 / Date—? -+ -7 (Applicant SCA T ��p/ ,�2/L%l��i��1 Top FAU _W.H.. Hood , Fan _Other_ CITY Ste.�/� ,e : �� el No.. NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— LICENSE OR 7� Exemption, you, should become subject to' the Workers' REG.NUMB �3 Class ER. Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSEZ 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 Inc]. FINAL DATE. ' y VALIDATIO LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. 3 I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and effect. Services License.Number ST i Lic.Class LI ! 0-200 Amp. Under 600 V � 201-1000 Amp. Under 600 V Contract 412i 1 ` 4e-Il/f61-Bate 72—Z%— � 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): 0 0 4 9,3 AMisc.Conduits&Conductors I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section # o'o.o o o 2 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 2 0 o.1 9, 5 0 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) 0 0 0 1 9,5 Q 5 issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 07. 27-81 Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE above 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 i ction purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ri� d�LP� '7 Z 7-2D/ ignature of Perr4kfee '� Date