The URL can be used to link to this page

Home My Public Portal About9437, 9441 , 9445 BROADWAY_Electrical__ �WORIYERS'COMPENSATION DECLARATION - 76A806 ,D;e, {� ,I llereby'affirm'that I have a certificate of consent to self insure, CE-aDeG APPLICATION FOR ELECTRICAL PERIIAIT. LJ or a certificate of Workers' Compensation Insurance,or a certified COUNTY OF LOS ANGELES B ILOING AND SAFETY c,{P(9Y('t�h,e,,T,a (JTG.'c. 800;Ca]Jh�`�C.) _ — _�`t;DmP2ny, - - FOR APPLICANT TO FILL IN - -JOB ADDRESS ❑ Certified copy is hereby furnished. - New Residential Bltlgs.8 Po s EACH NO. _ . FEE - ' A & 2-Family,S F 2 � $ — $ 'LOCALITY 'Certified copy is filed with the` nt building ' clip Y• Q' t. -department t" I Multi-family Sq.Ft. — NEAREST CROSS ) / ST. Date/ Applicant �- Residential Swimming Pools OWNER T FIRM NAME - CERTIFICATE OF.E%EMPTION FROM WORKERS'. Outlets: ./_!�l.�F.?tel / 7i7 _ ' :MAIL' COMPENSATION INSURANCE - - ADDRESS_ - (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 ( � I certify that in the performance of the work for which this permit PLAN CHECK• APP ,CANT 01/4 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 NOTICE TO APPLICANT: If, after making this Certificate of Fixed AppliancesNotOver 1 HP PERMIT r Exemption,you should become subject to the Workers'Compensation , _ Range_ Heater_ D.W. y— APPLICANT provisions..of the Labor Code,*you must forthwith comply with such ^Oven Dryer W.M. _ ADDRESS 10 provisions.or this permit shall be deemed revoked. Top F -Z= CITY A 4 LICENSED CONTRACTORS DECLARATION, - "Hoo am Other_ _ ,,hereby affirm that I am licensed under provisions of Chapter 9 ✓i _ UCEN EOR44 (commencing with Section 7000) of Division 3 of the Business and Disp. Room Air Cond: REG.NUMBER' ,p f ' •�� r Professions Code,and my license is 10 full force and effect. DISTRICT NO.. PROC BY Power Apparatus'& Large Appliances .. _ ,1 J Size&Type HP,KW,KVA,or KVAR 5. 06 V License Number 7 W6OC 17 Lic.Class Up to 1 Incl. FINAL �� L��]� AJDate , Over 1 to 10 Incl DATE jj --(�� VALIDATION O Im Contractor.• Over 10 to 50 Incl. FINAL 9 - U ❑ I am exempt under Sec. Over 50 to,t00,lnc. - BYow. 8.8 P.C. for this reason Over 100 [fie60 'Services,Swbd.,MCC& Panelboards" Z:7D - �—, j°1 Date: 0- 200 Amp.Under 600 V .v C Signature 201 - 1000 Amp.Under 600 VERE Over 1000 Amp.or Over 600 V 'd0 ❑ Exemption for Reg.Maint.Elect \_ Sa SINGLE FAMILY r t Temp.Power Pole.& Appurtenances / `j $1. ; HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit \ .. I hereby affirm that I am exempt from the Contractor's License Law \\\LTO .for the following reason (Section 703115, Business and Professions Additional Sign Branch Circuits, Code): - - Misc.Conduits& Conductors DONI-MOI -•y r7 p0 ❑ I.as owner of the property,will do the work and the structure' j 1 - ! Sw is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) . and Professions Code). D SJJ9\ 1 (:{'i/ �,.'.O CONSTRUCTION LENDING AGENCY _ - r - ,a ' I hereby affirm that there is a construction lending agency for the. 3;;07 u1.CK performance of the work-for which this.permit is issued(Sec 3097, PERMIT FEE - (Sub-Total) - 1 %• Civ. C.). O r, 'i _A W D IJ NEM i PLAN CHECKING FEE r � t.7 ]�} tT1 —'•. O Lender's Name " 'j Z ,_ 4 TGTi;L-/IS 3- 3>PERMIT ISSUING FEE I fel hrl Nh- Lender's Address' V tom*'' �'E�`�1H' 181`3,! certify that ,'have read this application and state that the above TOTAL FEE �j +. 3 F-' t'J' ?.. (��AM�.iL .110 information is correct. I agree to comply with all County ordinances V r j and State laws regulating Electrical wiring, and hereby authorize co4V T— TD ; representatives of this County to enter upon the above-mentioned' grope or inspectio rposes t� C� 9 C SEE REVERSE FOR EXPLANATORY LANGUAGE �� r� o ^ Ot]I) Lu71 121lE9 Sin ,e of Permittee Date YJ ^' . u - 1340 1 AM 9.4D r , /J g�l�go WORKERS'COMPENSATION DECLARATION 76A663 10/8I pp 1�1�p p p� 1� p (�,pgl� r� p p F�1�p(� g(„�. C I hereby affirm that I have a certificate of consent to self CE-806G APPLICATION lr ILICP9T0®II CI F®II't ELECTRICAL�r 0 IK D'bPri lL PIG Y'(ItlOI0 insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN ADDRESS Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ❑ Certified copy is filed with the county building nspec- I & 2-Family, Sq. Ft. S — E LOCALITY P tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. _ P Date Applicant OWNER ORC FIRM NAME /C-A-IT CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light $w. 'MAIL COMPENSATION INSURANCE First 20 ADDRESS A� e (This section need not be completed If the work involved by Total No CITY Tel. No. tho'permit is for one hundred dollars ($100)or less.) Additional a certify that in the performance of the work for which this PIAN CHECK permit is issued, APPLICANT shall not employ any person in any manner ' so as to become subject to the Workers'Comps anon Laws. Lighting Fixtures First 20 ADDRESS ' Total No. Additional CITY Tel. No. Date T: If, oft Fixed Appliances Not Over 1 HP PERMIT p �+rrq NOTICE TO APPLICANT: If, after making Ihi Certificate of APPLICANT 1?W JC/ � 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 .] �Q�� with comply with such provisions or this permit shall be Top _ FAU —W.H. J� deemed revoked. CITY //< -_U Tel. No. 1 LICENSED CONTRACTORS DECLARATION. Hood Fan _Other_ LICENSE M /J /O I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NBER � Class. OR `— (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES D and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances " D� Size 8 Type HP, KW, KVA, or KVAR r O License Num r Lia ClassUp to 1 Incl FINAL V �� Q�� Over 1 to 10 Incl. DATE — VALI TION O Contractor ate-1� / Over 10 to 50 Incl. FIN / V ❑ I am E exempt under S . - Over 50 Io 100 Inc. BV B.&P.C. for this reason Over 100 Services, Swbd., MCC &'Ponelboords Z Date. 0 -200 Amp. Under 600 V1,00,41� 6 9 3 4 A Signature 201 - 1000 Amp. Under 600 Ve�e e e e # t. 2 ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Mainz. Elect. (-e,a 2 ra 5.0 SINGLE FAMILY Temp. Power Pole& Appurtenances = HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit e e e `Z S.5 0 v I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and O 2 9:t.8 7 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors - 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) _ (Sea3097, Civ. C.). PLAN CHECKING FEE - Lender's Name `a PERMIT ISSUING FEE G Lender's Address 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 hereby authorize representatives of this County to enter upon the ove mentionedprope y for inspection urpo es SEE REVERSE FOR EXPLANATORY LANGUAGE Signalure of Fermin t Crate