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Home My Public Portal About9574 BROADWAY_Electrical__ WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT I herehy'�{firm that I have a certificate of consent fa self CE-806G 6 insure certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a...erlified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS / LjJLA Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. S = S LOCALITY T tion d Multi-family Sq. Ft. NEAREST part e t CROSS ST. Residential Swimming Pools Date Applicant OWNER OR RM NAME C TIFI ATE OF EXEMPTION FROM WORKE ' Outlets: RecLight_Sw. 'NAIL ///1�� j COMPENSATION INSURANCE ADDRESS C1 (This section need not be completed if the work involved by First 20 - �fp go the permit is for one hundred dollars SI00 or less. Total No. Additional CITY I. No. 1�D I certify that in the performance of the work for which this PLAN CHECK - permit is issued, 1 shall not employ any person in any manner APPLICANT so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional - CITY Tel. No. Date Applicant - Fixed Appliances Not Over I HP PERMIT NOTICE n, APPLICANT: If, after making this Certificate of APPLICANT Q Exemption, you should become subject to the Workers' Range_ Heoter_D.W. rn � t Compensation provisions of the Labor Code, you must forth- Oven Dryer — W.M._ ADDRESS I r with comply with. such provisions or this permit shall be Top FAU —W.H. deemed revoked. CITY 12 1e el. No. LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other— Disp. — Room Air Cond. LICENSE OR (49 1 Class. 1 1 hereby affirm that am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCE 'ED Y and Professions Code,and my license is in full force and effect. lT � d Size &Type HP, KW, KVA, or KVAR' V r O License Nuer is - U ol� Up to 1 Incl. FINAL Contract Over 1 to 10 Ind. DATE ,2 VALIDATI ❑ - Over 10 to 50 Incl. FINA V I am exempt and Sec. Over 50 to 100 Inc. BV // d B.&P.C. for this reason Over 100 Services, Swbd., MCC & Ponelboards D Z Date: 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 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 6 6 Q 7 A I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits ° • e • e Law for the following reason (Section 7031.5, Business and #. 2 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors II ° - 2550 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D " 255 .Q v 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 0 a 02 -'8.7 1 hereby affirm that there is a construction lending agency for 1 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 rend this application and store that the TOTAL FEF above information is correct. I agree to comply with all County ordinances and State lows regulating Electrical wiring, and hereby authorize representatives of this County gter upon _ the o y-Tnerl roperty forpectian r os U ' SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ure of Permin e - Date WORKERS'COMPENSATION DECLARATION 76A663 p /7 CE 806G (280) APPLICATION FOR ELECTRICAL PERMIT yiull I hereby 2ffirm"tTmt I have' a certificate of consent to self COUNTY OF LOS ANGEL G AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or I I J - a certified copy thereof(Sec. 3800, Lab. C.) .. Policy No: Company FOR APPLICANT TO FILL IN JOB S I /�r.�r(DoQ New Residential Bldgs.&Pools EACH NO. FEE ADD y Certified copy,is hereby furnished. 1 &'2-Family,Sc. Ft. $ — $ NLO CEAREST ALITV ry) I e- Cliq- 5?� Multi-family Sq. Ft.Certified copy is filed with the county building inspection - - CROSS ST ' departure t.' � Residential Swimming Pools OWNER OR - Date I I IS_IAUt r IOI ' L �l�l.+�. FIRM NAME Ka pplicant Outlets: Rec.;%Light Sw. AIL -7 r nit First 20 DDRESS I I 7 IV CERTIFICATE OF.EXEMPTION,FROM WORKERS' Total No. Additional CITVr VrO No. -IQ COMPENSATION INSURANCE � .+ PLAN CHECK (This section need not be completed if the work. involved APPLICANT 0 by the permit is for one hundred dollars ($1Lighting Fixtures First 20 00) or less.) Additional ADDRESS 0 Total No. cc I certify that in the performance of the work for which thisCITV. Tel No. 0 permit is issued, i shall not emIo an Fixed Appliances Not Over 1 HP P p y y person in any manner ^ PERMIT L) so as to become subject to the Workers' Compensation Laws. Range_-Heater�t D.W'. - "APPLICANT Q m E W n Oven _ Dryer_W.M. ADDRESS I Date I I. Applicant PCILIA Oh EI ln Ct, Top — FAD _W.H. - " - 'a 581 og Hood _ Fan _Other_ CITYn Ga r el No. NOTICE TO•APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR Exemption, you should become subject to the Workers' - REG.NUMBER lass Compensation provisions of the Labor Code, you musbforth- Power Apparatus& Large Appliances DISTRICT NO, /y P E ED.BV with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW, KVA,or KVAR Up to 1 Incl. FINAL - DATE / „ O LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. - f VALIDATION - - - � Over 10 to 50 Incl. _ I hereby affirm.that I am licensed under provisions of Chapter Over 50 to 100 Inc, JFINAL 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 /p effect. - 'Services - License Number a I W tic.Class C I O 0-200 Amp. Under 600 V 201-1000 Amp. Under 600 V Contractor Q m or Date I I I Over 1000 Amp.or Over 600 V , HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances _ Sign with One Branch Circuit - I hereby affirm that I am exempt .from the, Contractor's Additional Sign Branch Circuits License Law for the following reason (Section 7031.5, Busi- ' ness and Professions Code): - Misc.Conduits&Conductors ❑ I, as owner of the property, will do the work and the .Other (See Complete Fee Schedule)— 2.3 0 6 9 A structure is noflintended or offered for sale (Section 7044, Business and Professions Code). # o e s o e 2 CONSTRUCTION LENDING AGENCY ' I hereby affirm that there is a construction lending agency 2.65 0 for the performance of the work for'which this permit is PERMIT FEE ' (Sub-Total) 1 issued (Sec. 3097,Civ.C.). 00026506 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address �• 1,4-8 0 PERMIT ISSUING FEE D 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. - herebv authorize representatives of this County to enter upon the above,-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Cp?Lt QQioi. p Sign(Jure of rmittee l ate -