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Home My Public Portal About4843 ARDEN DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A663 CE-806 10,81 APPLICATION FOR ELECTRICAL PERMIT CE-806G. I hereby affirm that I have a certificate of consent to self insure, or-a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(,5ec.,387 Lab.C.) ' Policy No. �� z. Company _Tl�� FOR APPLICANT TO FILL IN JOB L1r—ilJfADDRESS Certified copy is hereby,furnished. New Residential Bldgs.& Pools. EACH NO. FEE ' $ _ $ LOCALITY Certified copy is filed''with the county building inspection 1 & 2-Family,Sq.Ft. /�a�Q department. Multi-family Sq.Ft. — NEAREST CROSS ST. Date, :�. Applicant ' / �� Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS/ MAIL COMPENSATION INSURANCE Outlets:Rec—Light — Sw. — 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' Js 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 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.— LICENSED CONTRACTORS DECLARATIONHood — Fan Other,_ CITY Tel.Not! I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR o (commencing.with Section 7000) of Division.3 of the Business and Disp. Room Air Cond., NUMBER (� Class.' _ Professions Code,and my license is in full force and effect. DISTRICT NO. PR SEo BY Power Apparatus& Large Appliances - _ Size&Type HP,KW,KVA,or KVAR" ��0 0 License Number Lic.Class 4!� /U Up to 1 Incl. FINAL V Over 1 to 10 Incl. DATE � �/ b L VALIDATION Contractor - i U Date F_ Over 10 to 50 Incl. F1 „I FINAL am exempt under SecU . Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 N Services,Swbd.,MCC& Panelboards , Z Date: 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 Additional Sign Branch Circuits for the following reason(Section 7031.5, Business and Professions Code): --3-;7 I a` c•; Misc.Conduits& Conductors T I_: ' ❑ I,as owner of the property,will.do the work and the structure 3 `T !F_= is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). t T E_€�_A 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.3097, PERMIT FEE (Sub-Total) O •I3r�1`.`'=(3L Civ:C.). PLAN CHECKING FEE Lender's Name ' ys,- _ PERMIT ISSUING FEE q.1 ._t c Lender's Address -- - !is` "�°-- 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 purpos �� - SEE REVERSE FOR EXPLANATORY LANGUAGE Sighaffir&of Permittee Date N .that I'S have aceSATION DECLARATIONto 76A34(iDPW 9/89 APPLICATION FOR PERMIT 11 E : GREEN, I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING copy thereof(Seca 3800 Lab. C.) Policy No.�_WGIof 651('Company H �. I �f;1) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. Certified copy is filed with the count building inspLOCALITY FOR APPLICANT TO FILL IN BUILDING `/ department. (PRINT OR TYPE ONLY) ADDRESS o "�3 f r Date I �' Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 'CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the ASSESSOR MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) -AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION I FLOOR BTU a VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. IL License Number �� Lic.Class Contractor , Date Z,96 ONO. Q El am exempt under Sec. Plan Check fee V B.&P.C.for this reason PERMIT ISSUING FEE$ 13 O Dater TOTAL FEE Signature 10 G LU OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U) Z I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions y Code): ADDRESS EJoyt I, as owner of the property, or my employees with wages -= as their sole compensation, will do the work and the CITY TEL.NO. f�[_j=) structure is not intended or offered for sale (Section 7044, `"` Business and Professions Code). OWNER LM,� W OLN�i G ;ENS' ❑ I, as owner of the property, am exclusively contracting MAIL ,�11 vV r 1:"; HL F-7 00 with licensed contractors to construct the project (Sec- ADDRES1S_ Q Y V U� tion 7044, Business and Professions Code). CITY F ( �h TEL.NO. 5 —� HE-C,� �`f _'{ CONSTRUCTION LENDING AGENCY ►••� 1_"_K1 i I hereby affirm that there is a construction lending agency for �/G , I:"�"j�€NGE the performance of the work for which this permit Is issued CONTRACTORILo U �� (Sec.3097,Civ.C.). ADDRESS L C� vim_ ✓ +i€13-I—?€_; ;•t +Tt Lender's Name n- CITY Yt TEL.NO. �X 1 g --T Lender's Address ✓ v 1 i STATE LIC. I certify that I have read this application and state that the above LICENSE NO. � 3 CLASS r' information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representati s df this County to enter upon the above-mentioned property i s iT ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �yRE FAP 1 TDATE `1