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HomeMy Public PortalAbout9217 BLACKLEY ST_Electrical__ ,'WORKERS' COMPENSATION DECLARATION a6A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self .CE806G insure., or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified co is hereb furnished. EACH NO. FEE ADDRESS 1 PY Y New Residential Bldgs. & Pools El Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY TEMPLE CITY tion department. Multi-family Sq. Ft. NEAREST ENCINIT Residential Swimming Pools CROSS ST. TAH FANG NSIN A AVE Date Applicant OWNER OR 77 ff��jj FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RelL�Tight—TSWA MAIL COMPENSATION INSURANCE First 20 1 ADDRESS SAME ABOVE pp Q' (This section need not be completed if the work involved by Total NoAdditional CITY VSO�7a 28��0 the permit is for one hundred dollars'($100)or less.) . . Y I certify that in the performance of the work for which this PLAN CHECK APPLICANT 11J permit 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 Q o ADDRESS Additional CITY Tel. No. Total No. Date Applicant jj�� NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT APPLICATION �"rl'' Exemption, you should become subject to the Workers' Range— Hepter—D.W. _ Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS47 with .comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY �ui G'r Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of The Business Power Apparatus& Large Appliances DISTRICT NO. PggrESSFD BY >-• and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR �10/ Q License Number Lic. Class Up To 1 Incl. FINAL C1 Over 1 to 10 Incl. DATE // - VALIDATION Contractor Date [/ 2. O aOver 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 jj�� W Services, Swbd.; MCC& Panelboards Z Date: 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits :R#_,= Professions Code): r (� Conduits& Conductors Misc. ?-" t LL�I I, as owner of the property, will do the work and the -• _ structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , s f _ .t j o, '�_ Business and Professions Code CONSTRUCTION LENDING AGENCY E aR j I he affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) O `3! 1 A (Sec. 3097, Civ. C.). 1411 PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the I TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and her by authorize representatives of this County to enter upon th ove- e tioCd grope for inspect'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE-806G (2-80) APPLICATION FOR LECTRICAL PERMIT CE-806 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES n BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) FILL JOB Policy No. Company FOR APPLICANT TO EACH NO. FEE ADDRESS 7W New Residential Bldgs.&Pools T ❑ Certified copy is hereby furnished. 1 &2-Family,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 m7Te� L Date Applicant Outlets: Rec.—Light Sw. MAIL �^ First 20 1 ADDRESS �7rJ'l CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.aF� 1&141 } COMPENSATION INSURANCE PLAN CHECK IL APPLICANT O' (This section need not be completed if the work involved V Additional . by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First onal ADDRESS cr Total No. O I certify that in the performance of the work for which thisFixed Appliances Not Over 1 HP Tel No. U permit is issued, I shall not employ any person in any manner PERMIT so as to become subject to the Wor rs' Compensation Laws. Range_ Heater_D.W. APPLICANT a Oven _ Dryer_W.M._ ADDRESS 'T� � V Date '�' Applicant u Top _ FAU _W.H. �/ Z Hood _ Fan _Other_ CITY JoL46—ei Tel No NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR �q Exemption, you should become subject to the Workers' REG. NUMBER.- ne �� /� Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO, PR ES D BY with comply with such provisions or this permit shall be deemed revoked: Size&Type HP,KW,KVA,or KVAR -� �• Up to 1 Incl. FINAL Over 1 to 101ncl. DATE VALIDAT ON LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ness and Professions.Code, and my license is in full force and effect. Service ? License Number .S� �� Lia Class l �� 0 200-Amp. Under 600 V / / /� 201-1000 Amp.,Under 600 V 'rPNktf5ctor'A �� �' Date c90--3 Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances Sign with One Branch Circuit O b 2 1 A I he affirm that I am exempt from the Contractor's Additional Sign Bunch Circuits License Law for the following reason (Section 7031.5, Busi- # 0'-0 0.0 2 ness and Professions Code): ' ' . I ' • Misc.Conduits&Conductors 2 0 o 1 9,5 0 ❑ 1, as owner of the property, will do the work and the Other (See Complete Fee Schedulg)— ' structure is not intended or offered for saleSection 7044, Business and Professions Code). sale ( °r°.° 1 9, 50" CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0 0 4—8.1' for .the performance of the work for which this, permit is PERMIT FEE (Sub-Total) . issued (Sec. 3097,Civ.C.). ' 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 above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and herebyorize repr sentatives of this County to enter upon the ab v -mentione roperty nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date '