Loading...
HomeMy Public PortalAbout9321 BLACKLEY ST_Electrical__ WORKERS' COMPENSATION DECLARATION DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O 76A663 I hereby affirm that I have"a certificate of consent to self .76A663 CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 380> C.) Policy No. Company FOR APPLICANT TO FILL IN JOB I(�Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY , 70147 NEAREST tion department. Multi-family Sq. Ft. -Residential Swimming PoolsCROSS-ST Date Applicant OWNERO FIRM NAME CERTIFICATE OF EXEMPTI N FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS First 20 (This section need not be completed if the work involved by Total No. Additional CITY — Tel. No. the permit is for one hundred dollars (=100)or less.) PLAN CHECK 1 certify that in the performance of the work for which this APPLICANT 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 ADDRESS Additional Total No. Cl Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION i Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be lop FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBE Class. (commencing with Section 7000)of Division 3 of the-Business Power Apparatus & Large Appliances DISTRICT IN ESSED BY d and Professions Code,and my license is in full force and effect. �� ��f� Size &Type HP, KW, KVA, or KVAR V08 0 License Number�� I I Lic. Class _ Up to 1 Incl. FINAL U Contractor �� 41114&Z- Date (,� Over 1 to 10 Incl. DATE �� VALIDATION o so Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. gY U W Over 100 W BP.C. for this reason .& Services, Swbd., MCC& Panelboards Date: 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 in oc HOME OWNER-BUILDER DECLARATION I herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit p Additional Si Law for the following reason (Section 7031.5, Business and n Branch Circuits Sign Professions Code): 5307 ,'rte.00I Misc. Conduits&Conductors �_ ❑ I, as.owner of the property, will do the work and the i 3 {'�. structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— ® Business and Professions Code). TOT AL __1 3 ® 00 CONSTRUCTION LENDING AGENCY CHECK 3L::1101 I hereby affirm that there is a construction lending agency for 7 °CIE; performance of the work for which this permit is issued PERMIT FEE (Sub-Total) CHANGE (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name n4./­)v =1; PERMIT ISSUING FEE 3 V Lender's Address 2 ^� 91831 1 AM _` I certify that I have read this application and state that the TOTAL FEE 3,300)] 30 above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby uthorize re es ntativ o;,�e ' County.to enter upon the ab ve-mention p ert rction purposes. ; ��--� SEE REVERSE FOR EXPLANATORY LANGUAGE s- gnature of Permiittee Date © WORKERS' COMPENSATION DECLARATION - 1081 CE-806G APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of cQ'nsent to self insure, C or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.J8EIGQLat"C.) 1� + Policy No. Company , � T FOR APPLICANT TO FILL IN JOB ❑ Certified co is hereby furnished. EACH NO. FEE ADDRESS 3�' PY� Y New Residential Bldgs.& Pools ❑ 1 & 2-Family,S Ft._ d $ — $ LOCALITY T Certified copy is filed with the county building inspection y 4 --- --�° department. r NEAREST (? Residential Swimming Pools CROSS Date � ' �� Applicant l�N� �G O OWNER OR FIRM NAME - / CERTIFICATE OF EXEMPTION N FROM ORKERS' Outlets:Rec— Light _ Sw. AMAIL DDRESS j/� /U b (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 el.No. 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 Total No. Additional 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 G ,C provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer — W.M._ ADDRESS e provisions or this permit shall be deemed revoked. Top — FAU — W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other— CITY el.N 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 S Zl Class.Gr Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT N PRO, S D Y Size& Type HP,KW,KVA,or KVAR j ��- License Number Lic. Class G f 10 Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE Contractor.Lb HWA L�� Date ALIDATION O ❑ Over 10 to 50 Incl. FINAL 1— I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 (L, Services,Swbd.,MCC& Panelboards ® (((////7 N Date: Z0- 200 Amp.Under 600 V Signature Le µ l,gam✓ 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 e I hereby affirm that I am exempt from the Contractor's License Law ACCT for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits °g Code): 31E7 17°35 ❑ ITEMS •, I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1iTEi titl�j is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ -g 1 _ and Professions Code). , TOTAL 62 m 35 CONSTRUCTION LENDING AGENCY CHECK 161°35 1 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 °I►1J Civ. C.). PLAN CHECKING FEE 0000--0001 c% 4/90 Lender's Name PERMIT ISSUING FEE Lender's Address 01507 1 AN 3:07 1 certify that I have read this application and state that the above TOTAL FEE C 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. y SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Datp