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Home My Public Portal About4910 ARDSLEY DR_Electrical__ WORKERS'COMPENSATION DECGARATibN' CE-806G (2-bbl APPLICATION FOR ELECTRICAL PERMIT CE-806 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.) W,11 91-iloff ltl S ,�,�K FOR APPLICANT TO FILL EACH N NO. FEE JOB �O AVE'Policy No. 7 ompany /sir) AIV / New Residential Bldgs.&Pools ADDRESS G Certified copy is hereby furnished.' 1 &2-Family,Sq. Ft. $ — $ LOCALITY !VPAIVZF ❑ copy Multi-family Sq. Ft. — NEAREST Certified is filed with the county building inspectionCROSS ST ew- Residential Swimming Pools' ACV- department. OWNER OR F RM NAME LEo Date Applicant Outlets: Recs—,Light 3 Sw.j6— AIL First 20 ADDRESS SAAAC CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE PLANCHECK �- APPLICANT O (This section need not be completed if the work involved d •� U by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS Additional cc Total No. O _ I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. (— permit is issued, I shall not employ any person in any manner PERMIT �t W so as to become subject to the Workers' Compensation Laws. Range_Heater_D.W. APPLICANTA4,&669 a Oven _ Dryer_W.M._ ADDRESS Date Applicant Top _ FAU , IV. � Z Hood F n Other_ B1 /� � CITY U/, �V�Na Tel N NOTICE TO APPLICANT: If, after making this Certificate of Disp. oom Air Cond.— ( LICENSE OR Exemption, you should become subject 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 deemed revoked. Size&Type HP,KW, KVA,or KVAR r Up to 1 Incl FI Over 1 to 10 Incl. DA EL LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. —� �3 VALIDATION I hereby'affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL p 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY V ness and Professions.Code, and,my license is in full force and effect. ��j�� QQ Services 1 pev rJ ri/! License Number 3K Lic.Class Q—/ 0-200 Amp. Under 600 V 201-1000 Amp. Under 600 V Contractor,Al(!JAO 81114AM 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): 2A 1 S 7.A Misc.Conduits&Conductors El 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— o 0 0 0 0 2 structure is not intended or offered for sale (Section 7044, Business and Professions Code). 2 0 "o 4030 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 1 o o o 4 0 3 0 x U for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,civ.C.). 0528-82 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 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 ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above- a tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE q4ulv- SignRure of Permit ate • WORKERS'COMPENSATION DECLARATION 76- 10/81 APPLICATION FOR ELECTRICAL PERMIT e. ',. I Rfreby affirm.that I have a certificate of consent to;:ielf igsy" CE-806806G!�;, ,, or46�certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY opy±.her of(Sec.3800,Lab. C.) ,.q Policy No: Company ��`��`��` "'' FOR APPLICANT TO FILL IN JOB 1<2 ADDRESS 14) ElCertified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection _ department. Multi-family Sq. Ft. r NEAREST CROSS ST. Date ` ApplicantResidential Swimming Pools OWNER OR FIRM NAME �. CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec l� Light Sw. AIL , . COMPENSATION INSURANCE AADDRESS (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. IP Additional CITY e� e�el�o. I certify that in the performance of the work for which this permit PLAN CHECK 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 Total No. Additional CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of 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 �— � � r 000 provisions or this permit shall be deemed revoked. Top — FAU W.H. ` 3 LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY Tel. No. , —� I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. — Room Air Cond. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER S S r Class. Professions Code,and my license is in full force and effect. DISTRICT NO. OC S BY Power Apparatus& Large Appliances Size& Type HP,KW,KVA,or KVAR t LicenseNumber 6 S 'T� Lic.Class Up to 1 Incl. FINAL 0, U Over 1 to 10 Incl. DATE / VALIDATION Contractor-Dy ��/Ar:&J Date 0 Over 10 to 50 Incl. FINAL O ❑ I am exempt under Sec. Over 50 to 100 Inc. BY �✓��r/ U W B.&P.C.for this reason Over,.00 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 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for for the.following reason (Section 703 1.5, Business and Professions Additional Sign Branch Circuits Code): . 3307 31.90 ❑ 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) and Professions Code). TOTAL 31-90 CONSTRUCTION LENDING AGENCY CHECK ulo7�f 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) CHANGE .00 Civ.C.). PLAN CHECKING FEE Lender's Name s "13190PERMIT ISSUING FEE _ Lender's Address � G9j 1 AM 7:461 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 purposes. SEE REVERSE-FOR EXPLANATORY LANGUAGE Signature of Permittee Date