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Home My Public Portal About4879 ARDSLEY DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76- 10/81 APPLICA`QUN FOR ELECTRICAL PERMIT I.hereby affirm that I have a certificate of consent to self insure, CE-806G o� 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 ,1❑ r ./•+• Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 1 & 2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection — NEAREST department. Multi-family Sq.Ft. CROSS ST.' Date Applicant Residential Swimming Pools OWNER OR ° Z1,44FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light --V-- Sw. 5 MAIL COMPENSATION INSURANCE ADDRESS �►� , (This section need not be completed if the work involved by the First 20 CITY �— TW No. permit.is for one hundred dollars($100)or less.). Total No. Additional ! D 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 Q V . Additional Total No.. CITY 0 Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT ! q' 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 provisions or this permit shall be deemed revoked. Top FA _ W.H. CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. (commencing with Section 7000) of Division 3 of the Business and — Room Air Cond. REG.NUMBER Class. Professions Code,and my license is in full force and effect. DISTRICT NO. PROC Power Apparatus& Large Appliances a� Size& Type HP,KW,KVA,or KVAR J` Q 0 License Number Lic.Class 'Up to 1 Incl. FINAL U. Over 1 to 10 Incl. DATE �� Lq/ VALIDATION Contractor Date Over 10 to 50 Incl. FINAL f U 0. I am exempt under Sec. 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 F-1Exemption 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 a s for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits �t-�' ir �C{o�dee))- r:L{ tl e l i rs L� I,as owner of the'property,will do the work and the structure Misc.Conduits&Conductors. 1 ITEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) L ff�' and Professions Code). ® {;{ ski CONSTRUCTION LENDING AGENCY (; j`_;E, ' f{Q(•{r' 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) 4•i{E NG,E Civ.C.). PLAN CHECKING FEE Lender's Name 0 L{11{_—01j°f''•1 i=1:, 1/9-1 PERMIT ISSUING FEE Lender's Address _ �' I certify that I have read this application and state that the above TOTAL FEE Ai° � 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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE A ot C> Signa ure of Permittee Date ^- 1^/ORKERS'COMPENSATION DECLARATION 76-663 10/81 CE-Bose APPLICATION FOR ELECTRICAL PERMIT I her affirm that I have a certificate of copse self insure, or a certificate of Workers'�m�pensatio�nance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,La Policy No. nFOR APPLICANT TO FILL IN JOB ❑ Certified copy ereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS ❑ Certfi icopy is filed with the county building inspection1 & 2-Family,Sq.Ft. $ — $ LOCALITY / C e tment. Multi-family Sq.Ft. — NEAREST CROSS ST. Da Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. — MAIL , �Tel .No.COMPENSATION INSURANCE ADDRESSTotal No. Additional CITY--I—.(This section need not be completed if the work involved by the First 20 permit is for one hundred dollars($100)or less.) . 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 IliTotal No. CITY Tel.No, Dat Applicant NOTICE T Fixed Appliances Not Over 1 HP APPLICANT: If, after making this Certificate of PERMIT -R 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.��W LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ LICENSE I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBE Class �f f Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSE BY �j /� _/ \ Size& Type HP,KW,KVA,or KVAR �� 0 License Numbers Lic.Cl ss (/ Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE/-,7 Contracto�� Date l � V DATION 0 ❑ Over 10 to 50 Incl. FIN 1--' I am exempt under Sec. r` Over 50 to 100 Inc. gy LU BAP.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 F-1Exemption 1000 Amp.or Over 600 V $4 6,4 A Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole& Appurtenances # 0 0 0 0.0 2 HOME OWNER-BUILDER DECLF ATION Sign with One Branch Circuit I hereby affirm that I am exempt from the ILontractor's License Law o o 3250 f/work llowing reason(Section 7031-. !Business and Professions Additional Sign Branch Circuits Misc.Conduits & Conductorss owner of the prop ,will do the work and the structure o 0 0 `3 25(7 c.>not intended oro red for sale (Section 7044, Business Other(See Complete Fee Schedule) ,d Professions de).CO RUCTION LENDING AGENCY 12 �1 ,87 Iaffirm at there is a construction lending agency for the Q pnce the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) PLAN CHECKING FEE LNamePERMIT ISSUING FEE LAddress 11 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 inspectio purpo es. �. SEE REVERSE FOR EXPLANATORY LANGUAGE r Signature of Permittee Ate