The URL can be used to link to this page

Home My Public Portal About4839 ARDEN DR_Electrical__ WORKERS'COMPENSATION DECLARATION C -663 1081 APPLICATI lil FOR ELECTRICAL PERMIT �f I hereby'affirni that I have a certificate of consent to self insure, E-906G or a certificate•of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) {T–. Policy No. Company- 1�� IF4,r.� FOR APPLICANT TO FILL IN JOB LrJy ADDRESS Certified copy is hereby furnished. ��- New Residential Bldgs.& Pools EACH NO. FEE Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ �6 — $ LOCALITY department. Multi-family Sq.Ft. — NEAREST _ i CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKER Outlets:Rec— Light Sw. MAIL COMPENSATION INSURANCE 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 Tel.No. • 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 Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate' of APPLICANT ! - Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS 7 L provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel. I hereby affirm that I am licensed under provisions-of Chapter 9 Disp. — Room Air Cond. LICENS O U REG.NUMBER Class. (commencing with Section 7000)of Division 3 of the Business and S b Professions Code,and my license is in full force and effect. .DISTRICT NOPR CESSED BY Power Apparatus& Large Appliances } 9 Size•&Type HP, KW,KVA, or KVAR i�(� 0 License Number l) I ic.Class jl—rt; Up to 1 Incl. FINAL /� V J _ Over 1-to 10 Incl. DATE Z 6 [ Z VALIDATION 0 ' Contractor Date Over 10 to 50 Incl. FINAL U ❑ 1 am exempt under Se . 9 / Over 50 to 100 Inc.. BY W B.&P.C.for this reason Over 100 Date: Services,Swbd.,MCC& Panelboards , Z 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& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law ^: T a 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' Misc.Conduits& Conductors structure j i is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ and Professions Code). , Fl_;I,r."L 16te +, I CONSTRUCTION LENDING AGENCY i?, F e3 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) d CHFiSdL L'• 3 Civ. C.). PLAN CHECKING FEE Lender's Name j ;r;j ; ,�•_ s ;° PERMIT ISSUING FEE { Lender's Address ` � certify (') I certify that I have read this application and state that the above TOTAL FEE / _ , 7. 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 inspectio, purposes S SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS' COMPENSATION DECLARATION 76- to/at APPLICATION FOR ELECTRICAL PERMIT l I hereby affirm that I have a certificate of consent to self insure, CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ EACH NO. FEE ADDRESS Certified copy is hereby furnished. New Residential Bldgs. & Pools MI 1 & 2-Family, Sq.Ft. $ — $ LOCALITY IV Certified copy is filed with e county building inspection — dep rtm t Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSS ST. O Date Applicant 's ,�;�MJV OWNER OR V FIRM NAME ClinsC- CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light — Sw. MAIL COMPENSATION INSURANCE 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 Tel. I certify that in the performance of the work for which this permit PLAN CK APPLICANT JS issued, I shall not employ any person in any manner so as to become subject t the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. Date ' Applicant Y IX� � Fixed Appliances Not Over 1 HP NOTICE TO A PLICANT: .If, after making this Certificate of ERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT t �DJ/��Af?-_ibpwa tr4c provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS a�U€ 3� provisions or this permit shall be deemed revoked. Top — FAU _ W.H. ,LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY L Tel.No. I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER 5_9 3S" Class. t Professions Code,and my license is in full force and effect. DISTRICT NO. PR SED 8Y Power Apparatus.& Large Appliances 47 Size& Type HP,KW,KVA, or KVAR Q� V License Number 4� Lic.Class Up to 1 Incl. FINAL P � Over 1 to 10 Incl. DATE VALIDATION Q Contractor n1. w&V abate Over 10 to 50 Incl. FINAL U ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W n' B.&P.C.for this reason Over 100 Date: Services,Swbd.,MCC & Panelboards ► 0- 200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V F1 Exemption 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. 1 SINGLE FAMILY Temp.Power Pole & Appurtenances j. HOME OWNER-BUILDER DECLARATION Sin with One Branch Circuit C-C � I hereby affirm that I am exempt from the Contractor's License Law g Fi'•.L•s a a for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ❑ y��'� Misc. Conduits & Conductors 1 I L9!O I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , illy_ —,,b` - and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the CHANGE o Ijl i performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ. C.). y �� ']'� /'I� PLAN CHECKING FEE ACID--•i 0 1 Lender's Name ofa l� W j y( 4i p I � PERMIT ISSUING FEE �- 5-5 i AM Voil Lender's Address I certify that I have read this application and § to that the above TOTAL FEE information is correct. agree to comply with all County ordinances and State laws reg. ting Electrical wiring, and hereby authorize representatives of W County to enter upon the abdve-mentioned property for inspe n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE G 9 _ Signat o Per i ee Date