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Home My Public Portal About9439, 9441 BROADWAY_Electrical__ 1 VORIiERS'COMPENSATION DECLARATION 76-663 10761 APPLICATION FOR ELECTRICAL PERMIT , {I J h,ryby affirm that I have a certificate of consent to self insure, CE-606G LJ pr;ayceruhAcate of Workers' Compensation Insurance, or a certified COUNTYIOF LOS ANGELES BUILDING AND SAFETY P cy NO: ,3&00" Company "'-S' FOR APPLICANT TO FILL IN JOB ❑ Certified copy Is hereby furnished EACH NO. - FEE ADDRES ,y ,J _ - Y New Residential Bltlgs. 8 Po Is -r ❑ Certified copy is filed with the 1 & 2-Family,Sq.FL z ,LOCALIT -� c f - • y builoi ipectin depart ant. Multi-family Sq.Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applican OWNER OR CERTIFICATE OF EXEMPTION FROM WORKERS' - _ - - 'FIRM NAME MAIL - COMPENSATION INSURANCE Outlets:Ree. ^ I int,(.__;; ry ADDRESS (This section need not be completed If First 20 the work involved by the permit is for one hundred dollars($100)or less.). Total No. AdditionaCITYl - Iv/ ' I certify that in the performance of.the work for,which this permit,;. ,_ PLAN CHECK APPLICANT ' is issueQ I shall not employ any.person in any mannerso as to become subject to the Workers'Compensation Laws. lighting Fixtures 2� First 20- ADDRESS, - -- - Additional f ' Total No.� CITY Tel.No. _ Date - - Applicant Fixed Appliances Not LICANOver. HP - NOTICE TO APPT: If, after making this Certificate of - PERMIT .Exemption,.you should become subject to the Workers'Compensation' APPLICANT CL Range_ Heater_ D.W.— L r -rX provisions of the Labor Code,you must forthwith comply with such., Oven Dryer _ W.M._ .ADDRESS fb I o r" provisions or this permif.shall be deemed revoked. _ Top FAUN' W.H. 'LICENSED CONTRACTORS DECLARATION -�- - CITY �o 1,6o Hood _ fan Other_ - I hereby affirm that am.licensed under provisions of Business and --�� LICENSE OR G. Disp. Room Air Cond. REG.NUMBER Class (commencing with Section 7000) of Division 3 of the Business ono .� Professions Code,and my license is til full force and'effeet.'' DISTRICT NO. PROCE D BY Power Apparatus& Large.Appliances F n 0 {{p(� Size 8 Type HP, KW,KVA,or KVAR (J t�j ..�i� Q License Nummbb'eer 0" ? Lia Class w^/v - Up to 1 Incl. FINAL ✓ContractdrJ%�l�.�i�zT"GTau - Over 1 to 10 Ind. DATE CYC/ -.x(17 VALIDATION- 1'96 Date`y(7 Over 10 to 50 Incl o ❑ I am exempt under Sec. `-�'C - Over 50 to 100 Inc. FINAL / 1 I}r BY. ..rr'� B.BP.G.for this reason Over 100 TOTAL' 4 C> m JiN Services,Swbd.;MCC& Panelboardsti D [a�Ctil 1 j5, .Z Date: 0- 200 Amp.Under 600 V ` Signature 201 - loon Amp.Under 600 V CHANGE .00 ,- ❑ - - Over 1000 Amp.or Over 600 V Exemption for Reg.Maiht.Elect. ' SINGLE FAMILY _ Temp.Power Pole& Appurtenances1`5 0C _ 0000-11GO1 2/. 1/89. HOMEOWNER-BUILDER DECLARATION {, Sign with One Branch Circuit - M I hereby affirm that I am exempt from the Contractor's License Law 1'44 1 Aft 947 for the following reason(Section 7031.5,Business and Professions Additional Sign Branch.Circuits Code): - - ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors - - - is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D 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(Sec 3097, PERMIT FEE (Sub-Total) - - - Civ.C.). PLAN CHECKING FEE Lender's Name - PERMIT ISSUING FEE ( ) Lender's Address 1 - I certify that I have read this application and state that the above TOTAL FEE 3 r, 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 proper ,r inspection r ses. _ SEE REVERSE FOR EXPLANATORY LANGUAGE z=z, -Signature of Permittee - Date WORKERS'COMPENSATION DECLARATION 76A663toter For.by, affirm that I have a certificate of consent to self CE-806G APPLICATION FOR ELECTRICAL PERMITinsure, 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 r JOB - Certified copy is hereby furnished. New Residential Bldgs. & Pools .EACH NO. FEE '� ADDRESS ❑ Certified copy is filed with the county building inspeo- y, Sq. Ft. LOCALITY -ii&Shigqte tion.department. - Multi-family 5q. Ft. — NEAREST e_a)E,ZL Residential Swimming Pools OWNER CROSS T. Dale Applicant - OR �S C,,)e,Lt � FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw. MAILADDRESS - COMPENSATION INSURANCE : : ( This,sech P 9 tion need not be completed if the work involved ' First 20. - - - the permit is for one hundred dollars ($100)or lass.) Total No. Additional CITY Tel. No. I certifythat in the erformance'of the work for which this PLAN CHECK P 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 (^'////��'_I�/L, ,-`J Total No. Additional Data �'�2— Applicant�,� CITY Tel. No. NOTICE TO APPLICANT: If, after making. this C rnficate of Fixed Appliances Not Over I HP PERMIT rn�r "' �- Exemption, you should become subject. to the Workers' Range_ Heater_D..-W. APPLICANT ILTS LLC [ L [ Compensation provisions of the Labor Code, you must forth- Oven Dryer — W.M._ ADDRESS1 E Ifs with comply with such provisions or this permit shall be - Top FAU —W.H. deemed revoked. CITY n/TC Tel. No. y�7Z LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other— Disp. Room Air Cond. LICENSE M �1 ��L � Class. I hereby affirm that am licensed under provisions of Chapter 9 REG. NUMBER !�//�' -1(J (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROC S BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances /' CL �� Size & Type HP, KW, KVA, or KVAR' 45� (/ O License No at n9 Lic. Class_L� Up to 1 Incl. JF'�' NAL - V C: Over 1 to 10 Incl. TE .�fj VALIDAT N O III Contracto Date�1-(-4L_ Over 10 to 50 Incl. ❑ NAL t— I am exempt under Sec. Over 50 to 100 Inc. Y 1 / p /Q /1f, �^ au au IL B.&P-C. for this reason Over 100 vC/L G /QV3A Z Services, Swbd., MCC & Panelboards , 1 /� # Dote: - 0 -200 Amp. Under 600 V r Signature 201 - 1000 Amp. Under 600 V - 2550 ' ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. 2 15 V SINGLE FAMILY Temp. Power Pole&.Appurtenances '( �' �. 2-8 T HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractors License Additional,Sign Branch Circuits Law for the following reason (Section 7031.5, Business-and Professions Code):' ❑ I, as owner of the pro err Misc. Conduits& Conductors - p p or offered do the work and the D siructure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 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) (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 5 above information is correct. I agree to camp with all County _ ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon 1' t above-mention d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �y� Signature of Per ittee Dote