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Home My Public Portal About9325 BROADWAY_Electrical__ i WORKERS'COMPENSATION DECLARATION 76A663 10/91 h1?reby affirm that I have a certificate of consent to self insure, CE-8066 APPLICATION FOR ELECTRICAL PERMIT ' or a�certificate.of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy/dam/Y�om�q/�'�(Sec.3800,Lab.C.) Policy.NO:' / _ C Company �f V„ - , FOR APPLICANT TO FILL IN - - - JOB ��r /jD ' r }y ❑ Certifietl copy is hereby furnished NewResidential Bldgs.& Pools EACH NO. - FEE • ADDRESS J ,C /�-� W/� Certified copy is filed with the county building.inspection 1 & 2-Family,Sq.Ft. S y LOCALITY �e' �--•i T department.e //'� �//� '1 _Muiti-family Sq.Ft. CROSS OWNER -.C�' 7 Applicant `•' 'v 44 U('W 6��n Residential Swimming Pools OWNER OR6N FIRM NAME .CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rao_ Light _,Sw MAIL p ./ COMPENSATION INSURANCE - ADDRESS af. P?,)4 PV4 / (This section need not be completed if the work involved by the First 20 permit is for oneCITY Tel.No.,hundred dollars($100) or less.) / 'Total No. Additional 2 .- Oz0 .� PLAN CHECK' I certify,that h l not a employ of person i any which this.permit '" ,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 - Date Applicant - 'CITY Tel.No. NOTICE TO' APPLICANT: If, after making this^Certificate of Fixed Appliances Not Over 1 HP PERMIT 4EExemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT (,'O /t provisionsof the tabor Code, you must fort hwith'comply with such Oven _ Dryer _ W.M._ ADDRESS A) 5VG�N�`•'{ 1 provisions or this permit shall be deemed revoked.. Top — FAU W.H.'_.' _ -. Lp� "�1 " LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ r - CITY p Tel.No. JS I,hereby affirm that I amlicensed under provisions of Chapter 9 LICENSE OR Q g ) Disp. Room Air Cond.-- y Olass. ' (commencing with Section 7000 of Division 3 of the Business and REG.NUMBER V 7 Professions Code,and my license is in full tome and effect. DISTRICT NO. ESSEDBY - Power Apparatus 8 Large Appliances � 0 _ _ } 'y/p7 �. Size 8-Type HP;KW.KVA,or;KVAR UY aO License Nu//m//,,b)�er I s`��yLic.Class�C�O �J - - Up to 7 Incl FINAL/�y - V Coritractor��.�gF COwN J"Date � Over 1 to 101nc1. DATE_ / R'•Y - - VALIDATION ❑ Over 10 to 50 Inc]. l •U FINAL q ,I am exempt under Sec. Over 50 to 100 Inc. - gy �� .. - . - . . OW.. B.BP.C. for this reason Over 100 N Date: Services,Swbd.,MCC& Panelboards _' D - - .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.Pourer Pole 8 Appurtenances _ _ 2 _ 'HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit a` I hereby-affirm that I am exempt from the Contractor's License Law ACCT.. vn.. for thCodele following reason (Section 7031.5,Business and Professions' Additional Sign Branch Circuits, a - .7.71.17 17.,.R4 Misc.Conduits& Coriductors ❑ I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) - 1 ITEMS is not intended or offered for sale (Section 7044, Business TOTAL " 17. 5O and Professions Code). CONSTRUCTION LENDING AGENCY - r- ` M��IC�K�' 17.50 1 hereby affirm that there is a construction lending agency for the - - CT ANE - .Wperformance of the work far which this permit is issued(Sec.3097„ PERMIT FEE - - (Sub-Total) - - - - - - Civ.C.). PLAN CHECKING FEE - - -Lender's Name OOW-lFVV1 Lender's Address 9�,rLy PERMIT ISSUING FEE - . . ._. W9 ,1 AM 9:08 - JCT 1 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 -party to inspection Pur l/v/// q SEE REVERSE FOR EXPLANATORY LANGUAGE- ' � /' / �? Signature Zf Permittee Date - WORKERS'COMPENSATION DECLARATION CE-806 loiBl APPLICATION PP ICA TION IGT ftp f�,p•' Ric ii p' PERMIT �f RMIT� I hereby affirm that I have a certificate df consent to self CE-806G i"i lr Ir IL `>t.PV Ytl FOR IG IL IG'�.r 0 Y'l '1 i"i 1L Ir IG Y'iYHE 0 insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3600, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS dS I� H/ Certified copy is hereby furnished. I New Residential Bldgs. 8 Pools EACH NO. FEE CL ❑ 1 8 2-Family, r- Certified copy is filed with the county building inspec- y, Sq. Ft. $ — $ LOCALITY 7 gl @ eC, tion department. Multi-family Sq. Ft. — 'NEAREST ` s Residential Swimming Pools CROSS ST. Date Applicant OWNER OR ' FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light_Sw. MAIL COMPENSATION INSURANCE - First 20 ADDRESS S &A-? ��p� (This section need not be completed if the work involved by Tocol No. Additional CITY Tel. No.�D 7�Y60 the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this PLAN CHECK permit is issued, I shall not employ any person in any manner APPLICANT so as to become subject to the Workers'Compenscitior ow= Ughting Fixtures First 20 ADDRESS 3 3c�[(� Total No. Additional Dote -1s-94- ss 1 Applicant CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over I HP PERMIT Exemption,'you should become subject to the Workers' Range— Heater_D.W. — APPLICANT Compensation provisions of the Labor Code, you.must forth- Oven _ Dryer _ W.M._ ADDRESS with comply with such provisions or this permit shall be Top _ 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. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. - PROCE ED BY and Professions Code,and my license is in full force and effect. P/ 6 Size 8 Type HP, KW, KVA, or KVAR' S !0 J O License Number Lic. ClassU Up to 1 Incl. FINAL �— Over I.to 10 Incl. DATE VALIDATION OC Contractor Date Over 10 to 50 Ind. FIN O ❑ I am exempt under Sec. Over 50 to 100 Inc. B 1 B.BP.C. for this reason Over 100 Z Date. Services, Swbd., MCC 8 Ponelboards D 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit P 0 9 1.8 A I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits t'y eyes o Professions Code): � , e2 ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors .2'0.-'v'b 5 0 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— eae30,5 0 D s 7044, Business and Professions Code). t CONSTRUCTION LENDING AGENCY _ 0 5 0 2—8 (L 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name _ PERMIT ISSUING FEE U Lender's Address I certify that I have read this application and state that the TOTAL FEE 3 G- ..l 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 ave-mentioned ropl rty for inspection purrp,osses.y SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 76A66 WORKERS't I have SATION cotDECLARATION corse CE-806 10/8I APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES T C BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB EACHNO. FEE ADD RESs r Certified copy is hereby furnished. New Residential Bldgs. & Pools - ❑ 1 8 2-Family, LOCALITY r� Certified copy is filed with the county building inspec- ri Sq. Ft. $ — S /)/1 Ci ! r tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Residential Swimming Pools Date Applicant OWNER OR FIRM NAME / /I v0O/I L AT ii1 N CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION MAIL Outlets: Rec Light-_ SW. ' COMPENSATION INSURANCE i � i ADDRESS - Llhe his section need not be com lased if the work Involved b First 20 r P Y Total No. [ P CITY Tel. No * p/ permit is for one hundred dollars($100)or less.) Additional a>iL f pY6 ertif that in the PLAN CHECK y performance of the work for which this PPLICANrmit is issued, 1 shop not employ a .Peron in anymanner as to become subject to the Wor /Q/pe a on Laws. Lighting Fixtures First 20 ADDRESS C Total No. Additional �J� CITY Tel. No. ' Date / Applican Fixed Appliances Not Over 1 HP. ter PERMIT TO APPLICANT: If, a r making this Certificate of APPLICANT " -Y . L. '.S Exemption, you should become subject to the Workers' Range_ Heater_D.W. _ Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M._ ADDRESS. .with comply with such provisions or this permit shall be Top _ FAU —W.H. — CITY y deemed revoked. Hood _ Fan _ Other— _:P" - /o Tel. No. LICENSED CONTRACTORS DECLARATION tICENS I hereby affirm that I am licensed under provisions of Chapter 9 Ao Disp. _ Room Air Cond. REG. NUMBER -'�0 Class. (commencing with Section 7000) of Division 3 of the Businesspower Apparatus 8 Large Appliances DISTRICT NO. PROC SED BY and Professions Code, and my license is in full force and effect. SQt� d Size 8 Type HP, KW, KVA, or KVAR' d O License Number ;j-ZL� Lic Class �'— �TFINAL 1 � Up to 1 Incl. DATE ,t--i C Over 1 to 10 Incl. L — VALIDATION Contractor Date Over 10 to 50 Ind. V ❑ FINAL am exempt under Sec. Over 50 to 100 Inc. eY W B.BP.C. for this reason Over 100 N Services, Swbd., MCC 8 Ponelboards !! ? Date: 0 - 200 Amp. Under 600 V (A 6 Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V %6903 ,11 Exemption for Req. Mains. Elect. #f e a e e o SINGLE FAMILY Temp. Power Pole 8 Appurtenances ' 'z HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 2 °t° 4 4.G 5 I hereby affirm that I am exempt from the Contractor's License h Circuits rcus e ° ° Additional Sign Brait Law for the following reason (Section 7031.5, Business and 4 Q.2 5J1 Professions Code): ❑ I, as owner of the property, will do_the work and the Misc. Conduits 8 Conductors ,.) 7, 1 7 -8.3 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D 7044, Business and Professions Code). - 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 PERMIT FEE (Sub-Total) 3 _. (Sec. 3097, Civ. C.). ' PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE r�s above information is correct. I agree to comply with all County ordina nc and State laws regulating Electrical wiring, and here uthorize represenlativ pF this County to enter upon the 'ove-mention d pr ' rl fd'r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _ Signature o r iu a Dat -