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Home My Public Portal About5830 CLOVERLY AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806G (2-80) CAPPLICATION FOR -ELECTRICAL PERMIT CE-806 [� t I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES " BUILDING AND SAFETY U insure', or a'certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) FOR APPLICANT TO FILL IN ,JOB Policy No. Company EACH NO. FEE ADDRESS J o G New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY �Cd4 /./� Zlky Multi-family Sq. Ft. — NEAREST c 7v' v A Certified copy is filed with the county building inspection CROSS ST J T department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: Rec.—Light Sw. MAIL �I T* ��►�. First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY COMPENSATION INSURANCE } PLAN CHECK a (This section need not be completed if the work involved APPLICANT 0 U Lighting Fixtures First io ADDRESS by the permit is for one hundred dollars ($100) or less.) � Total No. Additional O I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY T U permit is issued, I shall not employ any person in any manner PERMIT LL so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT a Oven _ Dryer_W.M. ADDRESS to Dat / e Too _ FAU _W.H.._ �OApplicant a CITY Tel No. Hood — Fan —Other NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Rolm Air Cond.— LICENSE OR Exemption, you should, become subject to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances / DISTRICT NO. PROES ED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR �O� � deemed revoked. Up to 1 Incl. FINAL Over 1 to 10 Incl DATE VALIDATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. Thereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ' 4� ness and Professions.Code, and my license is in full force and effect. Services 0-200 Amp. Under 600 V License NumberLic.Class• / l ) 1 /� y 201-1000 Amp. Under 600 V Contractors �dK�Date ®'/s�& 6 . Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances f��a A:7 G I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits 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 b, 6 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY # 0 0 0 oto 2 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) ✓ D 2 0 0 1 700. issued (Sec. 3097,Civ.C.). x Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) o o 1 7 0 0 c) Lender's Address PERMIT ISSUING FEE QA 7-80 I certify that I have read this application and state that the TOTAL FEE , 7 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 e bove- ned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date J ' WORKERS'COMPENSATIONDECLARATION CE-806 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES C BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or k//vfiod copy , 10(Sec. 3800, Lab.Com))* J f / FOR APPLICANT TO FILL IN JOB Policy No. �/✓CCCoompany ��✓ LL EACH NO. FEE ADORES S t�3G/ Q y - L New Residential Bldgs.&Pools ❑ Certified copy is hereby furnished. 1 &2-Family+Sq. Ft. 67, 00 $ — 1$ 137 I-D LOCALITY '4 Multi-family NEAREST XdepaCertified copy is filed with the county building inspection wmCROSS ST �/ .f' ;r r,tment. Residential Swimming Pools OWNER OR _ FIRM NAME G�l�-�'►��1 r CC's Date��/�/ Applicant ' Outlets: Rec.—Light Sw. MAIL First 20 ADDRESS �� / ,!•%��/� T /y�� + CERTIFICATE OF EXEMPTION FR M WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE (/��' �� `�� d PLAN CHECK o (This section need not be completed if the work involved APPLICANT U Additional by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First ADDRESS 0C Total No. 0Additional I certify that in the performance of the work for which thisF zed Appliances Not Over 1 HP CITY Tel No. permit is issued, I shall not employ any person in any manner PERMIT `+�/1 1C so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT V SCC Gs a Oven _ Dryer_W.M. ADDRESS 4T' t� /l/ "Z p//o/ff.//1K ��;; z_ Date Applicant Top FAU _W.H.. t'Z,,4l. "/7r1-aJJ7 Hood _ Fan _Other_ CITY �7 Tel 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 12 . Class G6 Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. 5 Up to 1 Incl. FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE q, —( 3 VALIDATION Over 10 to 50 Incl. ` Iry affirm that I am licensed under provisions of Chapter Over 50 to 100.Inc. FINAL BY 9 comebmencing with Section 7000) of Division 3 of the Busi- Over 100 nss and Professions Code, and my license is in full force and e fect. Services v ' IW G I 0-200 Amp. Under 600 V icense Number Lic. Class 1 Q^ 201-1000 Amp. Under 600 V Contractor /-�eA! Date Over 1000 Amp.or Over 600 V Sys-, HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances 3(j•1. 1 A I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason '(Section 7031.5, Busi- ness and Professions Code): Misc.Conduits&Conductors 2 ° 14 4 Jr 0 ❑ I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— I r _ ' structure is not intended or offered for sale (Section p ° ° 1 4 I,J 0 c5 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY V05-81 I hereby affirm that there is a construction lending agency for the performance of the work ,for which this permit is PERMIT FEE (Sub-Total) S issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 0 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 above-me 'Ron/e4 property for in ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE R Signature ermi ee D e )