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Home My Public Portal About5808 CLOVERLY AVE_Electrical__ 6C- LJ �7y 1 /3([� KERS' COMPENSATION DECLARATION 76A663 10/81APPL CATON FOR ELECT I E-806G CAL PERMIT C y a arm that I have a certificate of consent to self insure, j . ceortifigate of Workers' Compensation Insurance, or a certified �� 17 COUNTY OF LOS ANGELES BUILDING AND SAFETY copy therecd(Sec.3800,Lab.C.) {�j � J,/�/�/ j/f y Poticy No:• Company� ^-�^ " ' `''"_ 0 FOR APPLICANT TO FILL IN ' B P� �� Av " Certified copy is hereby furnished. New Residential Bldgs.-& Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY Certified copy,iso filed with the county building inspection NEAREST. department. ` Multi-family Sq.Ft.�l g'LJy'S. 3S — CROSS ST. k -1•-jq. Residential Swimming Pools OWNER OR �� licant u FIRM- Date pp ANAME/ C CERTIFICATE OF EXEMPTION FROM WORKERS', Outlets:Rec Lig W. MAIL ADDRESS7/ COMPENSATION INSURANCE This section need not be completed if the work involved b the rst ( y Total ' A rtional CITY � � Tel.No. permit is for one hundred dollars,,($100)or less.) PLAN CHECK I certify that in the performance of the work•for 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 F rst 20 • ADDRESS Additional ' Total No. � CITY - Tel.No. ' Date Applicant• Fixed Applian es Not O er T RP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range Hea D. APPLICANT ; provisions of the Labor Code, you must forthwith comply with such Oven D er ADDRESS provisions or this permit•shall be deemed revoked. TO — U H. CITY � � Tel.No. LICENSED CONTRACTORS DECLARATION H d Fan Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR P. Room Air Cond. 4r REG.NUMBER` Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. Power Apparatu & Large pliances _ DISTRICT NO. PROCESSED BY a:I Size& Ty HP,K V'A or KVA r as 0 :� �?^ Up t 1 Incl. FINAL U. License Number Lic.Class�� - (�-� Ov r 1 to 10 In DATE (.2 �. m ' VALIDATION Contractor Date �� er 10 to 5 Incl. ❑ I am exem�j under Sec. Over 501b 100 Inc. B :CT.11 .11 W 'B.&P.C.for this reason Over 10 � 1vu1 'Services wbd., CC-& Pan oar Date: - 200 mp.Under 0Y0 V 1 1[ENS Signature - 10 Amp. Un r 60 V ��IAL >�1� ��. F-1Exemptionver 1 0 Amp. or ver 0 V 1 " Exemption for Reg.Maint.Elect. CHECK 518n0 SINGLE FAMILY Temp. Power Pole& Appurtenances o00 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit CHANGE I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 0000-0001 71/16/89 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors 19225 $ AM110 n 3 1 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 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.)• Ltkee PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and sirye 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 property fo;inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ur of Permittee Date WORKERS'COMPENSATION DECLARATION 76A663 10/81 /l f l' I hereby afffirrrytthat I have a certificate of consent to self insure, CE-806G APPLIC TI N FOR ELECTRICAL PERM or w wrtificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof (C�S1[ec.34.8'npO.,L]ab. C.) /LL / G Policy No� gi ` ''(��mp / �� C� FOR APPLICANT TO FILL IN JOB .ei y ❑ Certified copy is hereby furnished. EACH NO., FEE New Residential Bldgs.& Pools ADDRESS ❑ 1 & 2-Family,Sq. Ft. $ _ $, LOCALITY "Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. NEAREST ! �t W CROSS ST. Residential Swimming Pools OWNER OR Date .Applicant FIRM NAME, CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light Sw. MAIL COMPENSATION INSURANCE First 20 ADDRESS MJ, yr—It Ala This section need not be completed if the work involved b ( • Y the Total No. Additional CITY X M � Tel. No. permit is for one hundred dollars ($100) or less.) CHECKPLAN I certify that in the performance of the work for 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 Additional Total No. CITY 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'Compensation Range_ HeaterD.W. APPLICANT , provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. ADDRESS 734— provisions 3 —provisions or this permit shall be deemed revoked. Top — FAU W.H. }per IQ CITY Tel.No LICENSED,CONTRACTORS DECLARATION Hood — Fan Othec— I hereby affirm that I am licensed.under provisions of Chapter 9LICENSE OR blo (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER 7V Class. Professions Code,and my license is in full force and effect. .DISTRICT NOPROCESSE Y ��-¢- Power Apparatus&Large Appliances 2% LicSize& Type HP, KW,KVA,or KVAR License Number "� �v Q .Class Up to 1 Incl. FINAL !� ,� (/ _ Over 1 to 10 Incl. DATE VA L ATION 0 Contractor I� I� 9 �Gf!� 1 �f� e f r lCj e.� Over 10 to 50 Incl FINAL — ❑ I am exempt under Sec. Over 50 to 100 Inc. BY BAP.C.for this reason Over 100 Z Services,Swbd.,MCC& Panelboards ► Date: 0-200 Amp.Under 600 V Signature 201 1000 Amp.Under 600 V Over 1000 Amp.or Over 600 V F-1 Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp. Power Pole & Appurtenances S 61 ;?0865A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0}0 0 2 I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code): 25,5.0 ❑ Misc.Conduits& Conductors 0 0 6 2 5 5 0w I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) is not intended or offered for sale (Section 7044, Business and Professions Code). I 0,06-88 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 I 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 Cou6ty to enter upon the above-mentioned property for inspection purposes. • SEE REVERSE FOR EXPLANATORY LANGUAGE . Signature of Permittee Date